Means and Methods for Determining a Clearance Normalized Amount of a Metabolite Disease Biomarker in a Sample

ABSTRACT

The present invention relates to a method for determining a clearance normalized amount of a metabolite disease biomarker in a sample including the steps of (a) determining the amount of the disease biomarker in at least a first type of sample of a subject suspected to suffer from the disease, (b) determining the amount of a kidney function biomarker which correlates with the glomerular filtration rate (GFR) in the said at least first type of sample, and (c) determining a clearance normalized amount for the metabolite disease biomarker by normalizing the amount determined for the metabolite disease biomarker in step (a) to the amount of the kidney function biomarker determined in step (b). Moreover, the invention also relates to a method for diagnosing a disease in a subject suspected to suffer therefrom and to a device for determining a clearance normalized amount of a metabolite disease biomarker in a sample.

The present invention relates to a method for determining a clearance normalized amount of a metabolite disease biomarker in a sample comprising the steps of (a) determining the amount of the disease biomarker in at least a first type of sample of a subject suspected to suffer from the disease, (b) determining the amount of a kidney function biomarker which correlates with the glomerular filtration rate (GFR) in the said at least first type of sample, and (c) determining a clearance normalized amount for the metabolite disease biomarker by normalizing the amount determined for the metabolite disease biomarker in step (a) to the amount of the kidney function biomarker determined in step (b). Moreover, the invention also relates to a method for diagnosing a disease in a subject suspected to suffer therefrom and to a device for determining a clearance normalized amount of a metabolite disease biomarker in a sample.

Small molecules such as various metabolites are usually excreted via the kidney. Accordingly, a proper kidney function it is decisive for a proper metabolite homeostasis. If the kidney function and, in particular, the glomerular filtration is impaired, the metabolites can no longer be excreted in usual amounts and may accumulate in the blood and other body fluids. Accordingly, the actual level for a given metabolite may be increased by improper kidney function rather than by other metabolic causes.

In the recent years, metabolic profiling has established a variety of promising metabolite disease markers for various diseases such as cardiovascular disease, metabolic diseases such as diabetes or metabolic syndrome or neurodegenerative disorders. It is essential to diagnose such disease efficiently and reliably. Usually, a disease causes an increase or a decrease, i.e. an alteration of the quantity, of metabolite biomarkers in body fluids such as blood. Such an increase or decrease will than be used as a diagnostic indicator for the presence, absence or risk for developing the disease. However, as set forth above, an improper kidney function may also affect the level of biomarkers in the blood including those which are suitable as disease metabolite biomarkers. Accordingly, a patient may be diagnosed to suffer from a disease such as a cardiovascular disease based on, e.g., an increase of a biomarker although said increase of the biomarker is caused by an impaired kidney function rather than by the cardiovascular disease. Accordingly, the patient will be classified falsely positive for the disease. Moreover, rather than addressing the renal impairment therapeutically, the patient will be treated for a probably non-existing cardiovascular disease.

Kidney function can be assessed by determining the glomerular filtration rate (GFR). To this end, creatinine clearance is conventionally determined. In addition to creatinine, GFR may also be determined by measuring the clearance of other compounds including exogenously applied once, such as inulins, or endogenous compounds, such as cystatin c (see, e.g., Grubb 1985, Acta Med Scand 218 (5): 499-503 or Simonsen 1985, Scand J Clin Invest 45(2): 97-101).

An impaired kidney function is normally taken into account for establishing a diagnosis by a medical practitioner. However, the kidney function parameter has not been used to directly adjust or correct biomarker levels.

Nevertheless, it would be highly desirable to have comparable levels for biomarkers between all types of patients including those with impaired kidney function.

The technical problem underlying the present invention can be seen as the provision of means and methods for complying with the aforementioned needs. The said technical problem is solved by the embodiments characterized in the claims and herein below.

Thus, the present invention relates to a method for determining a clearance normalized amount of a metabolite disease biomarker in a sample comprising the steps of:

-   -   (a) determining the amount of the disease biomarker in at least         a first type of sample of a subject suspected to suffer from the         disease;     -   (b) determining the amount of a kidney function biomarker which         correlates with the glomerular filtration rate (GFR) in the said         at least first type of sample; and     -   (c) determining a clearance normalized amount for the metabolite         disease biomarker by normalizing the amount determined for the         metabolite disease biomarker in step (a) to the amount of the         kidney function biomarker determined in step (b).

The method as referred to in accordance with the present invention includes a method which essentially consists of the aforementioned steps or a method which includes further steps.

However, it is to be understood that the method, in a preferred embodiment, is a method carried out ex vivo, i.e. not practised on the human or animal body. The method, preferably, can be assisted by automation.

The term “clearance normalized amount” as used herein refers to an amount for a metabolite biomarker which is adjusted or corrected for kidney function and, in particular for renal clearance.

The term “sample” as used herein encompasses any kind of biological sample which comprises metabolites and, preferably, also proteins. Accordingly, a sample in the sense of the present invention may be a biological fluid or a tissue or cell comprising sample. Preferably, the metabolites present in the said sample are affected by kidney function, i.e. their presence, absence and/or quantity may be altered by an impaired renal clearance. Typically samples such as blood or urine are immediately affected by the kidney function since improper renal clearance will, e.g., prevent the transmission of a metabolite from the blood into the urine. However, it will be understood that other samples such as saliva, liquor and the like may also secondarily be affected by an improper kidney function. Preferably, said sample is blood or a derivative thereof, such as plasma or serum or any other fraction of blood, or urine.

A first type of sample as referred to herein refers to either one first sample or different first samples from the same subject wherein said subject exhibits the same disease conditions when the said different first samples where taken and wherein the said different samples have been treated in an identical manner prior to the investigation by the method of the invention.

Accordingly, a second or further type of sample is to be understood as either one second or further sample or different second or further samples from a further subject being different from the subject from which the first type sample has been derived. Moreover, a second type of sample can also be derived from the subject from which the first type sample has been derived wherein said subject has underwent a treatment between deriving the first type sample and the second type sample or wherein a certain time period has passed between deriving the first type sample and the second type sample.

The aforementioned samples are, preferably, pre-treated before they are used for the method of the present invention. As described in more detail below, said pre-treatment may include treatments required to release or separate the compounds or to remove excessive material or waste. Suitable techniques comprise centrifugation, extraction, fractioning, ultrafiltration, protein precipitation followed by filtration and purification and/or enrichment of compounds. Moreover, other pre-treatments are carried out in order to provide the compounds in a form or concentration suitable for compound analysis. For example, if gas-chromatography coupled mass spectrometry is used in the method of the present invention, it will be required to derivatize the compounds prior to the said gas chromatography. Suitable and necessary pre-treatments depend on the means used for carrying out the method of the invention and are well known to the person skilled in the art. Pre-treated samples as described before are also comprised by the term “sample” as used in accordance with the present invention.

The term “subject” as used herein relates to animals and, preferably, to mammals. More preferably, the subject is a primate and, most preferably, a human. The subject, preferably, is suspected to suffer from a disease as specified herein.

The term “biomarker” as used herein refers to a molecular species which serves as an indicator for a disease or effect as referred to in this specification. Said molecular species can be a metabolite itself which is found in a sample of a subject. Moreover, the biomarker may also be a molecular species which is derived from said metabolite. In such a case, the actual metabolite will be chemically modified in the sample or during the determination process and, as a result of said modification, a chemically different molecular species, i.e. the analyte, will be the determined molecular species. It is to be understood that in such a case, the analyte represents the actual metabolite and has the same potential as an indicator for the respective medical condition. Moreover, a biomarker according to the present invention is not necessarily corresponding to one molecular species. Rather, the biomarker may comprise stereoisomers or enantiomeres of a compound. Further, a biomarker can also represent the sum of isomers of a biological class of isomeric molecules. Said isomers shall exhibit identical analytical characteristics in some cases and are, therefore, not distinguishable by various analytical methods including those applied in the accompanying Examples described below. However, the isomers will share at least identical sum formula parameters and, thus, in the case of, e.g., lipids an identical chain length and identical numbers of double bonds in the fatty acid and/or sphingo base moieties.

The term “kidney function biomarker” relates to a biomarker which is an indicator for proper kidney function, and, in particular, an indicator for proper renal clearance. Preferably, it is envisaged that such a kidney function biomarker is excreted under physiological conditions and, thus, present in a defined amount in, e.g., urine and/or blood. If the kidney function is impaired such that the renal clearance is altered for the said biomarker, the amounts present in either the urine or the blood or both will be changed, said change being indicative for the improper renal clearance and kidney function. Renal clearance is correlated to the glomerular filtration rate (GFR) which is the total amount of primary urine which is excreted by the glomeruli of the kidney within a certain period of time. The GFR is an essential parameter of proper kidney function. In human adults, the GFR is about 170 liters per day. Biomarkers which correlate to the GFR and which are, thus, suitable as kidney function biomarker in the sense of the instant invention encompass endogenous biomarker molecules, such as creatinine or cystatin c, or exogenously applied biomarker molecules, such as inulins.

Preferably, said kidney function biomarker is selected from the group consisting of cystatin C and creatinine. Cystatin c is a non-glycosylated, basic protein having an isoelectric point at about pH 9.3. Its three-dimensional structure is characterized by a short alpha helix and a long alpha helix running across a large antiparallel, five-stranded beta sheet. Cystatin c forms two disulfide bonds. About 50% of the cystatin c molecules in a subject carry a hydroxylated proline. Cystatine c forms dimers via subdomains wherein in the dimerized state, each half is made up of the long alpha helix and one beta strand of one partner and four beta strands of the other partner (see Janowski 2001, Nat Struct Biol 8(4): 316-320). Creatinine is a well known metabolite which results from creatine phosphate metabolic conversions in the muscle. More preferably, said kidney function biomarker is cystatin c.

The term “metabolite disease biomarker” as used herein refers to a biomarker which is an indicator for the presence of the disease or a predisposition for the disease. It will be, therefore, understood that the presence, absence or quantity of a metabolite disease biomarker as used herein is altered if a subject suffers from the disease or as a predisposition therefor. A disease in the sense of the present invention may be any health abnormality or disorder. Preferably, said metabolite disease biomarker is a biomarker for cardiovascular diseases or disorders, diabetes or metabolic syndrome or neurodegenerative diseases. Preferably, the said disease is a disease as recited in any one of tables 1 to 6 and 8 to 21. More preferably, said disease biomarker is a biomarker selected from any of tables 1 to 6 and 8 to 21. Moreover, it will be understood that more than one biomarker and up to all of the biomarkers recited in any one of the aforementioned tables may be determined as disease metabolite biomarker in the method of the present invention.

The term “determining the amount” as used herein refers to determining at least one characteristic feature of a biomarker to be determined by the method of the present invention in the sample. Characteristic features in accordance with the present invention are features which characterize the physical and/or chemical properties including biochemical properties of a biomarker. Such properties include, e.g., molecular weight, viscosity, density, electrical charge, spin, optical activity, colour, fluorescence, chemoluminescence, elementary composition, chemical structure, capability to react with other compounds, capability to elicit a response in a biological read out system (e.g., induction of a reporter gene) and the like. Values for said properties may serve as characteristic features and can be determined by techniques well known in the art. Moreover, the characteristic feature may be any feature which is derived from the values of the physical and/or chemical properties of a biomarker by standard operations, e.g., mathematical calculations such as multiplication, division or logarithmic calculus. Most preferably, the at least one characteristic feature allows the determination and/or chemical identification of the said at least one biomarker and its amount. Accordingly, the characteristic value, preferably, also comprises information relating to the abundance of the biomarker from which the characteristic value is derived. For example, a characteristic value of a biomarker may be a peak in a mass spectrum. Such a peak contains characteristic information of the biomarker, i.e. the m/z information, as well as an intensity value being related to the abundance of the said biomarker (i.e. its amount) in the sample.

As discussed before, each biomarker comprised by a sample may be, preferably, determined in accordance with the present invention quantitatively or semi-quantitatively. For quantitative determination, either the absolute or precise amount of the biomarker will be determined or the relative amount of the biomarker will be determined based on the value determined for the characteristic feature(s) referred to herein above. The relative amount may be determined in a case were the precise amount of a biomarker can or shall not be determined. In said case, it can be determined whether the amount in which the biomarker is present is enlarged or diminished with respect to a second sample comprising said biomarker in a second amount. In a preferred embodiment said second sample comprising said biomarker shall be a calculated reference as specified elsewhere herein. Quantitatively analysing a biomarker, thus, also includes what is sometimes referred to as semi-quantitative analysis of a biomarker.

Moreover, determining as used in the method of the present invention, preferably, includes using a compound separation step prior to the analysis step referred to before. Preferably, said compound separation step yields a time resolved separation of the metabolites comprised by the sample. Suitable techniques for separation to be used preferably in accordance with the present invention, therefore, include all chromatographic separation techniques such as liquid chromatography (LC), high performance liquid chromatography (HPLC), gas chromatography (GC), thin layer chromatography, size exclusion or affinity chromatography. These techniques are well known in the art and can be easily applied by the person skilled in the art without further ado. Most preferably, LC and/or GC are chromatographic techniques to be envisaged by the method of the present invention. Suitable devices for such determination of biomarkers are well known in the art. Preferably, mass spectrometry is used in particular gas chromatography mass spectrometry (GC-MS), liquid chromatography mass spectrometry (LC-MS), direct infusion mass spectrometry or Fourier transform ion-cyclotrone-resonance mass spectrometry (FT-ICR-MS), capillary electrophoresis mass spectrometry (CE-MS), high-performance liquid chromatography coupled mass spectrometry (HPLC-MS), quadrupole mass spectrometry, any sequentially coupled mass spectrometry, such as MS-MS or MS-MS-MS, inductively coupled plasma mass spectrometry (ICP-MS), pyrolysis mass spectrometry (Py-MS), ion mobility mass spectrometry or time of flight mass spectrometry (TOF). Most preferably, LC-MS and/or GC-MS are used as described in detail below. Said techniques are disclosed in, e.g., Nissen 1995, Journal of Chromatography A, 703: 37-57, U.S. Pat. No. 4,540,884 or U.S. Pat. No. 5,397,894, the disclosure content of which is hereby incorporated by reference. As an alternative or in addition to mass spectrometry techniques, the following techniques may be used for compound determination: nuclear magnetic resonance (NMR), magnetic resonance imaging (MRI), Fourier transform infrared analysis (FT-IR), ultraviolet (UV) spectroscopy, refraction index (RI), fluorescent detection, radiochemical detection, electrochemical detection, light scattering (LS), dispersive Raman spectroscopy or flame ionisation detection (FID). These techniques are well known to the person skilled in the art and can be applied without further ado. The method of the present invention shall be, preferably, assisted by automation. For example, sample processing or pre-treatment can be automated by robotics. Data processing and comparison is, preferably, assisted by suitable computer programs and databases. Automation as described herein before allows using the method of the present invention in high-throughput approaches.

Moreover, the at least one biomarker can also be determined by a specific chemical or biological assay. Said assay shall comprise means which allow to specifically detect the at least one biomarker in the sample. Preferably, said means are capable of specifically recognizing the chemical structure of the biomarker or are capable of specifically identifying the biomarker based on its capability to react with other compounds or its capability to elicit a response in a biological read out system (e.g., induction of a reporter gene). Means which are capable of specifically recognizing the chemical structure of a biomarker are, preferably, antibodies or other proteins which specifically interact with chemical structures, such as receptors or enzymes. Specific antibodies, for instance, may be obtained using the biomarker as antigen by methods well known in the art. Antibodies as referred to herein include both polyclonal and monoclonal antibodies, as well as fragments thereof, such as Fv, Fab and F(ab)2 fragments that are capable of binding the antigen or hapten. The present invention also includes humanized hybrid antibodies wherein amino acid sequences of a non-human donor antibody exhibiting a desired antigen-specificity are combined with sequences of a human acceptor antibody. Moreover, encompassed are single chain antibodies. The donor sequences will usually include at least the antigen-binding amino acid residues of the donor but may comprise other structurally and/or functionally relevant amino acid residues of the donor antibody as well. Such hybrids can be prepared by several methods well known in the art. Suitable proteins which are capable of specifically recognizing the biomarker are, preferably, enzymes which are involved in the metabolic conversion of the said biomarker. Said enzymes may either use the biomarker as a substrate or may convert a substrate into the biomarker. Moreover, said antibodies may be used as a basis to generate oligopeptides which specifically recognize the biomarker. These oligopeptides shall, for example, comprise the enzyme's binding domains or pockets for the said biomarker. Suitable antibody and/or enzyme based assays may be RIA (radioimmunoassay), ELISA (enzyme-linked immunosorbent assay), sandwich enzyme immune tests, electrochemiluminescence sandwich immunoassays (ECLIA), dissociation-enhanced lanthanide fluoroimmunoassay (DELFIA) or solid phase immune tests. Moreover, the biomarker may also be determined based on its capability to react with other compounds, i.e. by a specific chemical reaction. Further, the biomarker may be determined in a sample due to its capability to elicit a response in a biological read out system. The biological response shall be detected as read out indicating the presence and/or the amount of the biomarker comprised by the sample. The biological response may be, e.g., the induction of gene expression or a phenotypic response of a cell or an organism. In a preferred embodiment the determination of the least one biomarker is a quantitative process, e.g., allowing also the determination of the amount of the at least one biomarker in the sample.

As described above, said determining of the at least one biomarker can, preferably, comprise mass spectrometry (MS). Mass spectrometry as used herein encompasses all techniques which allow for the determination of the molecular weight (i.e. the mass) or a mass variable corresponding to a compound, i.e. a biomarker, to be determined in accordance with the present invention. Preferably, mass spectrometry as used herein relates to GC-MS, LC-MS, direct infusion mass spectrometry, FT-ICR-MS, CE-MS, HPLC-MS, quadrupole mass spectrometry, any sequentially coupled mass spectrometry such as MS-MS or MS-MS-MS, ICP-MS, Py-MS, TOF or any combined approaches using the aforementioned techniques. How to apply these techniques is well known to the person skilled in the art. Moreover, suitable devices are commercially available. More preferably, mass spectrometry as used herein relates to LC-MS and/or GC-MS, i.e. to mass spectrometry being operatively linked to a prior chromatographic separation step. More preferably, mass spectrometry as used herein encompasses quadrupole MS. Most preferably, said quadrupole MS is carried out as follows: a) selection of a mass/charge quotient (m/z) of an ion created by ionisation in a first analytical quadrupole of the mass spectrometer, b) fragmentation of the ion selected in step a) by applying an acceleration voltage in an additional subsequent quadrupole which is filled with a collision gas and acts as a collision chamber, c) selection of a mass/charge quotient of an ion created by the fragmentation process in step b) in an additional subsequent quadrupole, whereby steps a) to c) of the method are carried out at least once and analysis of the mass/charge quotient of all the ions present in the mixture of substances as a result of the ionisation process, whereby the quadrupole is filled with collision gas but no acceleration voltage is applied during the analysis. Details on said most preferred mass spectrometry to be used in accordance with the present invention can be found in WO 03/073464.

More preferably, said mass spectrometry is liquid chromatography (LC) MS and/or gas chromatography (GC) MS. Liquid chromatography as used herein refers to all techniques which allow for separation of compounds (i.e. metabolites) in liquid or supercritical phase. Liquid chromatography is characterized in that compounds in a mobile phase are passed through the stationary phase. When compounds pass through the stationary phase at different rates they become separated in time since each individual compound has its specific retention time (i.e. the time which is required by the compound to pass through the system). Liquid chromatography as used herein also includes H PLC. Devices for liquid chromatography are commercially available, e.g. from Agilent Technologies, USA. Gas chromatography as applied in accordance with the present invention, in principle, operates comparable to liquid chromatography. However, rather than having the compounds (i.e. metabolites) in a liquid mobile phase which is passed through the stationary phase, the compounds will be present in a gaseous volume. The compounds pass the column which may contain solid support materials as stationary phase or the walls of which may serve as or are coated with the stationary phase. Again, each compound has a specific time which is required for passing through the column. Moreover, in the case of gas chromatography it is preferably envisaged that the compounds are derivatised prior to gas chromatography. Suitable techniques for derivatisation are well known in the art. Preferably, derivatisation in accordance with the present invention relates to methoxymation and trimethylsilylation of, preferably, polar compounds and transmethylation, methoxymation and trimethylsilylation of, preferably, non-polar (i.e. lipophilic) compounds.

The determination of the metabolite disease biomarker and the kidney function biomarker, preferably, may be carried out in the same aliquot of one first type sample or in different aliquots of one first type sample or aliquots of different first type samples. For example, the disease biomarker may be determined in an aliquot of a first first type sample and the kidney function biomarker is determined in an aliquot of a second first type sample. Alternatively, the disease biomarker may be determined in a first aliquot of a first sample and the kidney function biomarker may be determined in a second aliquot of said first sample. Still alternatively, the said disease biomarker and the kidney function biomarker may be determined simultaneously or consecutively in the same aliquot of a first sample.

A clearance normalized amount for the metabolite disease biomarker can be determined by any mathematical operation which establishes a relation between the determined amount of the metabolite disease biomarker and the amount of the kidney function biomarker such that the amount of the disease biomarker is put into relation to the kidney function. Such a relation can be established by adjusting or correcting the amount of the metabolite disease biomarker itself or by adjusting or correcting a parameter to be compared to the said amount of the metabolite disease biomarker such as a reference amount or threshold value. Preferably, the said normalizing in this context, i.e. in step (c) of the method of the invention, encompasses calculating a ratio of the amount determined for the disease biomarker in step (a) and the amount of the kidney function biomarker determined in step (b). It is to be understood that any form of correction for clearance effects can be carried out in accordance with the present invention in order to reflect a clearance normalized amount of a disease metabolite biomarker. For example, ratios, cut-off values or a linear and non-linear fits can be made. Moreover, also preferably encompassed is an analysis of variance (ANOVA) correction of the amount. By using ANOVA of parameters such as the amount of the metabolite disease biomarker in a diseased and a healthy group of subjects and the amount of a kidney function biomarker such as cystatin C, a correction factor can be calculated reflecting the difference between the predicted fit and the actual test fit underlying the ANOVA. Said correction factor can subsequently be applied to normalize an amount of the metabolite disease biomarker. Preferably, ANOVA correction is used for reflecting clearance normalized amounts for at least one metabolite disease biomarker in a comparison of different study set ups, such as different cohorts of subjects to be compared with each other with respect to the amount of at least one metabolite disease biomarker. Further, clearance normalization according to the invention may be, preferably, achieved by adjusting or correcting a reference amount or threshold value.

In a preferred embodiment of the method of the present invention, steps (a) and (b) are carried out for a second type of sample being different from the first type of sample and wherein said normalizing in step (c) encompasses calculating (i) a ratio of the amount determined for the metabolite disease biomarker in the first type and the second type samples, (ii) calculating a ratio of the kidney function biomarker determined in the first type and the second type samples, and (iii) calculating a ratio of the ratios calculated under (i) and (ii). Also preferably, said normalizing can encompass (i) determining the ratio of the metabolite biomarker and the kidney biomarker in the first sample and (ii) the ratio of the metabolite biomarker and the kidney biomarker in the second sample.

Advantageously, it has been found in accordance with the present invention that an impaired kidney function including improper renal clearance affects the blood metabolite levels of metabolic biomarkers. In particular, levels for metabolites in the blood including those which can serve as biomarkers are, in general, increased due to an improper removal by renal excretion. As a consequence, patients suffering from impaired kidney function may be diagnosed to suffer from disease base on said increased levels of metabolic biomarkers. However, in such patients, the change in the biomarker level is not caused by a disease but rather by an improper kidney function. Thanks to the present invention, a clearance normalized amount for a disease metabolite biomarker can be determined by taking into account a kidney function biomarker as a normalization parameter for the determined amount of one or several disease biomarker. Moreover, thanks to the said normalization, amounts for disease biomarkers can be compared between individuals more reliably since inter-individual clearance differences will be efficiently reduced. Thus, threshold amount such as the upper limits for physiological amounts for a biomarker can be more reliably established. More specifically, it was found in the studies underlying the present invention that a plurality of plasma metabolites correlated with cystatin c levels and, thus, with kidney function. Moreover, the data quality for plasma metabolites could be significantly improved after normalization to the cystatin c levels.

The definitions and explanations of the terms made above apply mutatis mutandis for the following embodiments of the present invention except specified otherwise herein below.

The present invention also relates to a method for diagnosing a disease in a subject suspected to suffer therefrom comprising:

-   -   (a) determining a clearance normalized amount for at least one         metabolite disease biomarker in a sample of said subject         according to the method of the invention specified above; and     -   (b) comparing said clearance normalized amount to a reference,         whereby the disease is to be diagnosed.

The term “diagnosing” as used herein refers to assessing whether a subject suffers from a disease as specified herein, or not. As will be understood by those skilled in the art, such an assessment, although preferred to be, may usually not be correct for 100% of the investigated subjects. The term, however, requires that a statistically significant portion of subjects can be correctly assessed and, thus, diagnosed. Whether a portion is statistically significant can be determined without further ado by the person skilled in the art using various well known statistic evaluation tools, e.g., determination of confidence intervals, p-value determination, Student's t-test, Mann-Whitney test, etc. Details are found in Dowdy and Wearden, Statistics for Research, John Wiley & Sons, New York 1983. Preferred confidence intervals are at least 50%, at least 60%, at least 70%, at least 80%, at least 90% or at least 95%. The p-values are, preferably, 0.2, 0.1, or 0.05.

The term includes individual diagnosis of a disease or its symptoms as well as continuous monitoring of a patient. Monitoring, i.e. diagnosing the presence or absence of the disease or the symptoms accompanying it at various time points, includes monitoring of patients known to suffer from the said disease as well as monitoring of subjects known to be at risk of developing the disease. Furthermore, monitoring can also be used to determine whether a patient is treated successfully or whether at least symptoms of the disease can be ameliorated over time by a certain therapy.

The term “disease” as used herein refers to any health abnormality or disorder in a subject. Preferably, said disease is a cardiovascular disease or disorder and, more preferably, congestive heart failure, diabetes or metabolic syndrome and, more preferably, diabetes type II, or neurodegenerative diseases and, more preferably, multiple sclerosis. More preferably, the said disease is a disease as recited in any one of tables 1 to 6 and 8 to 21.

The term “reference” refers to values of characteristic features of each of the biomarker which can be correlated to a medical condition, i.e. the presence or absence of the disease referred to herein. Preferably, a reference is a threshold value (e.g., an amount or ratio of amounts) for a biomarker whereby values found in a sample to be investigated which are higher than or essentially identical to the threshold are indicative for the presence of a medical condition while those being lower are indicative for the absence of the medical condition. It will be understood that also preferably, a reference may be a threshold value for a biomarker whereby values found in a sample to be investigated which are lower or identical than the threshold are indicative for the presence of a medical condition while those being higher are indicative for the absence of the medical condition.

In accordance with the aforementioned method of the present invention, a reference is, preferably, a reference obtained from a sample from a subject or group of subjects known to suffer from a disease as referred to herein. In such a case, a value for the at least one biomarker found in the test sample being essentially identical is indicative for the presence of the disease.

Moreover, the reference, also preferably, could be from a subject or group of subjects known not to suffer from a disease as referred to herein, preferably, an apparently healthy subject or group of healthy subjects. In such a case, a value for the at least one biomarker found in the test sample being altered with respect to the reference is indicative for the presence of the disease. The same applies mutatis mutandis for a calculated reference being, most preferably, the average or median for the relative value or the value for a degree of change of the at least one biomarker in a population of individuals (comprising the subject to be investigated). The relative values or degrees of changes of the at least one biomarker of said individuals of the population can be determined as specified elsewhere herein. How to calculate a suitable reference value, preferably, the average or median, is well known in the art. The population of subjects referred to before shall comprise a plurality of subjects, preferably, at least 5, 10, 50, 100, 1,000 or 10,000 subjects. It is to be understood that the subject to be diagnosed by the method of the present invention and the subjects of the said plurality of subjects are of the same species.

The value for the at least one biomarker of the test sample and the reference values are essentially identical, if the values for the characteristic features and, in the case of quantitative determination, the intensity values are essentially identical. Essentially identical means that the difference between two values is, preferably, not significant and shall be characterized in that the values for the intensity are within at least the interval between 1st and 99th percentile, 5th and 95th percentile, 10th and 90th percentile, 20th and 80th percentile, 30th and 70th percentile, 40th and 60th percentile of the reference value, preferably, the 50th, 60th, 70th, 80th, 90th or 95th percentile of the reference value. Statistical test for determining whether two amounts are essentially identical are well known in the art and are also described elsewhere herein.

An observed difference for two values, on the other hand, shall be statistically significant. A difference in the relative or absolute value is, preferably, significant outside of the interval between 45th and 55th percentile, 40th and 60th percentile, 30th and 70th percentile, 20th and 80th percentile, 10th and 90th percentile, 5th and 95th percentile, 1st and 99th percentile of the reference value. Preferred relative changes of the medians or degrees of changes are described in the accompanying Tables as well as in the Examples. In the Tables below, a preferred relative change for the biomarkers is indicated as “up” for an increase and “down” for a decrease in column “direction of change”. Values for preferred degrees of changes are indicated in the column “estimated fold change”. The preferred references for the aforementioned relative changes or degrees of changes are indicated in the Tables below as well. It will be understood that these changes are, preferably, observed in comparison to the references indicated in the respective Tables, below.

Preferably, the reference, i.e. values for at least one characteristic feature of the at least one biomarker or ratios thereof, will be stored in a suitable data storage medium such as a database and are, thus, also available for future assessments.

The term “comparing” refers to determining whether the determined value of a biomarker is essentially identical to a reference or differs there from. Preferably, a value for a biomarker is deemed to differ from a reference if the observed difference is statistically significant which can be determined by statistical techniques referred to elsewhere in this description. If the difference is not statistically significant, the biomarker value and the reference are essentially identical. Based on the comparison referred to above, a subject can be assessed to suffer from the disease, or not.

For the specific biomarkers referred to in this specification, preferred values for the changes in the relative amounts or ratios (i.e. the changes expressed as the ratios of the medians) are found in the Tables, below.

The comparison is, preferably, assisted by automation. For example, a suitable computer program comprising algorithms for the comparison of two different data sets (e.g., data sets comprising the values of the characteristic feature(s)) may be used. Such computer programs and algorithms are well known in the art. Notwithstanding the above, a comparison can also be carried out manually.

Moreover, the present invention relates to the use of a kidney function biomarker as defined elsewhere herein in a sample of a subject comprising a metabolite disease biomarker for normalizing said metabolite disease biomarker.

Further the invention relates to the use of a kidney function biomarker as defined elsewhere herein for manufacturing a diagnostic pharmaceutical composition for normalizing in a sample of a subject comprising a metabolite disease biomarker said metabolite disease biomarker.

The invention further relates to a device for determining a clearance normalized amount of a metabolite disease biomarker in a sample comprising:

-   -   a) an analyzing unit comprising a detection agent which         specifically detects the amount of at least one metabolite         disease biomarker and a detection agent which specifically         detects the amount of a kidney function biomarker; and     -   b) an evaluation unit comprising a data processor having         tangibly embedded a computer program code carrying out an         algorithm which normalizes the amount for the metabolite disease         biomarker to the amount of the kidney function biomarker.

A device as used herein shall comprise at least the aforementioned units. The units of the device are operatively linked to each other. How to link the means in an operating manner will depend on the type of units included into the device. For example, where the detector allows for automatic qualitative or quantitative determination of the biomarker, the data obtained by said automatically operating analyzing unit can be processed by, e.g., a computer program in order to facilitate the assessment in the evaluation unit. Preferably, the units are comprised by a single device in such a case. Said device may accordingly include an analyzing unit for the biomarker and for the kidney function biomarker and a computer or data processing device as evaluation unit for processing the resulting data for the assessment and for stabling the output information. Preferred devices are those which can be applied without the particular knowledge of a specialized clinician, e.g., electronic devices which merely require loading with a sample. The output information of the device, preferably, is a numerical value for the clearance normalized amount of a metabolite disease biomarker.

In a preferred embodiment of the device of the invention, said evaluation unit comprises a database with stored references which allow for diagnosing a disease based on the clearance normalized amount for the metabolite disease biomarker. In this case, the output information of the device allows drawing conclusions on the presence or absence of a disease and, thus, is an aid for diagnosis. More preferably, the output information is a preliminary diagnosis or an aid for diagnosis based on the aforementioned numerical value, i.e. a classifier which indicates whether the subject suffers from a disease or not. Such a preliminary diagnosis may need the evaluation of further information which can be provided in the device of the invention by including an expert knowledge database system.

A preferred reference to be used as a stored reference in accordance with the device of the present invention is an amount for the at least one biomarker to be analyzed or values derived therefrom which are derived from a subject or group of subjects known to suffer from a disease. More preferably the stored reference in accordance with the device of the present invention is an clearance normalized amount for the at least one biomarker to be analysed. In such a case, the algorithm tangibly embedded, preferably, compares the determined amount for the at least one clearance normalised biomarker with the clearance normalised reference wherein an identical or essentially identical amount or value shall be indicative for the presence of the disease in the subject.

Alternatively, another preferred reference to be used as a stored reference in accordance with the device of the present invention is an amount for the at least one biomarker to be analyzed or values derived therefrom which are derived from a subject or group of subjects known not to suffer from a disease. In such a case, the algorithm tangibly embedded, preferably, compares the determined amount for the at least one biomarker with the reference wherein an amount or value which differs from the reference shall be indicative for the presence of the disease in the subject. Preferred differences are those indicated as relative changes or degrees of changes for the individual biomarkers in the Tables below.

The units of the device, also preferably, can be implemented into a system comprising several devices which are operatively linked to each other. Depending on the units to be used for the system of the present invention, said means may be functionally linked by connecting each mean with the other by means which allow data transport in between said means, e.g., glass fiber cables, and other cables for high throughput data transport. Nevertheless, wireless data transfer between the means is also envisaged by the present invention, e.g., via LAN (Wireless LAN, W-LAN). A preferred system comprises means for determining biomarkers. Means for determining biomarkers as used herein encompass means for separating biomarkers, such as chromatographic devices, and means for metabolite determination, such as mass spectrometry devices. Suitable devices have been described in detail above. Preferred means for compound separation to be used in the system of the present invention include chromatographic devices, more preferably devices for liquid chromatography, HPLC, and/or gas chromatography. Preferred devices for compound determination comprise mass spectrometry devices, more preferably, GC-MS, LC-MS, direct infusion mass spectrometry, FT-ICR-MS, CE-MS, HPLC-MS, quadrupole mass spectrometry, sequentially coupled mass spectrometry (including MS-MS or MS-MS-MS), ICP-MS, Py-MS or TOF. The separation and determination means are, preferably, coupled to each other. Most preferably, LC-MS and/or GC-MS are used in the system of the present invention as described in detail elsewhere in the specification. Further comprised shall be means for comparing and/or analyzing the results obtained from the means for determination of biomarkers. The means for comparing and/or analyzing the results may comprise at least one databases and an implemented computer program for comparison of the results. Preferred embodiments of the aforementioned systems and devices are also described in detail below.

As set for the elsewhere herein, the normalization carried out by the evaluation unit encompasses an algorithm for calculating a ratio of the amount determined for the metabolite disease biomarker in step (a) and the amount of the kidney function biomarker determined in step (b). Said algorithm can be implemented by a computer program code tangibly embedded in a data processor comprised in the evaluation unit.

All references cited herein are herewith incorporated by reference with respect to their disclosure content in general or with respect to the specific disclosure contents indicated above.

The invention will now be illustrated by the following Examples which are not intended to restrict or limit the scope of this invention.

EXAMPLES Example 1 Disease Associated Metabolite Biomarkers

In the following tables 1 to 6, 8, and 9 to 21 disease related metabolite biomarkers are listed. The biomarkers can be determined and analyzed as described in any one of WO2011/092285 A2, WO2012/085890, WO2007/110357 or WO2007/110358. The nomenclature of lipids from the analysis of complex lipids has been applied like described in WO2011/092285.

Cardiac markers according to WO2011/092285:

Biomarkers not precisely defined by their name in any one of tables 1 to 6 are further characterized in table 7.

TABLE 1a Metabolites with a significant difference (p-value < 0.05) between patients with congestive heart failure (CHF) and healthy controls ratio of regula- Metabolite_Name median tion p-value Lysophosphatidylcholine (C18:2) 0.656 down 0.000002 Mannose 1.949 up 0.000000 Hypoxanthine 2.136 up 0.000006 Phytosphingosine 0.779 down 0.000010 Lignoceric acid (C24:0) 0.654 down 0.000029 Glutamate 2.027 up 0.000037 2-Hydroxybutyrate 1.724 up 0.000132 Lysophosphatidylcholine (C18:0) 0.820 down 0.000213 Behenic acid (C22:0) 0.744 down 0.000224 Tricosanoic acid (C23:0) 0.708 down 0.000237 Phosphatidylcholine (C18:0, C18:2) 1.028 up 0.000248 Linoleic acid (C18:cis[9,12]2) 0.733 down 0.000270 Pseudouridine 1.299 up 0.000321 Phosphate, lipid fraction 0.817 down 0.000333 Lysophosphatidylcholine (C18:1) 0.874 down 0.000432 Lysophosphatidylcholine (C17:0) 0.770 down 0.000612 erythro-Sphingosine (*1) 0.823 down 0.000620 Glycerol phosphate, lipid fraction 0.768 down 0.000628 5-O-Methylsphingosine (*1) 0.802 down 0.000766 Galactose, lipid fraction 0.775 down 0.000846 Cholesterol 0.855 down 0.000921 alpha-Ketoglutarate 1.235 up 0.000944 Histidine 0.790 down 0.000945 Eicosanoic acid (C20:0) 0.835 down 0.001148 3-O-Methylsphingosine (*1) 0.769 down 0.001248 erythro-C16-Sphingosine 0.827 down 0.001492 Uric acid 1.429 up 0.001696 Cholestenol No 02 0.821 down 0.004244 Urea 1.243 up 0.005073 Adrenaline (Epinephrine) 1.926 up 0.006118 Aspartate 1.120 up 0.006265 Normetanephrine 1.262 up 0.006469 Pentadecanol 0.583 down 0.006875 myo-Inositol, lipid fraction 0.775 down 0.007379 Dehydroepiandrosterone sulfate 0.594 down 0.007754 Phosphatidylcholine (C16:1, C18:2) 0.883 down 0.008776 Sphingomyelin (d18:1, C24:0) 0.943 down 0.011533 Threonine 0.855 down 0.012287 myo-Inositol-2-phosphate, lipid fraction 0.635 down 0.012637 (myo-Inositolphospholipids) Myristic acid (C14:0) 0.572 down 0.015030 Homovanillic acid (HVA) 1.292 up 0.015937 Arginine 0.844 down 0.016192 Glutamine 0.850 down 0.016336 Elaidic acid (C18:trans[9]1) 1.267 up 0.017410 4-Hydroxy-3-methoxyphenylglycol 1.128 up 0.019069 (HMPG) Cystine 1.105 up 0.020208 4-Hydroxy-3-methoxymandelic acid 1.179 up 0.020480 Zeaxanthin 0.699 down 0.021888 Glucose 1.215 up 0.023219 Stearic acid (C18:0) 0.918 down 0.023703 Cortisol 1.345 up 0.025615 3-Methoxytyrosine 1.209 up 0.026958 5-Hydroxy-3-indoleacetic acid (5-HIAA) 1.255 up 0.027467 Lysophosphatidylcholine (C20:4) 0.944 down 0.029167 Creatinine 1.208 up 0.031253 Heptadecanoic acid (C17:0) 0.828 down 0.032349 Proline 0.818 down 0.033617 Erythrol 1.224 up 0.035087 Nervonic acid (C24:cis[15]1) 0.879 down 0.035240 Coenzyme Q10 1.060 up 0.036613 Coenzyme Q9 0.774 down 0.040228 Phosphatidylcholine (C18:0, C18:1) 0.966 down 0.044253 Cryptoxanthin 0.464 down 0.047617 1,5-Anhydrosorbitol 0.808 down 0.047807 SM_Sphingomyelin (d17:1, C24:0) 0.7142 down 2.8E−13 SM_Sphingomyelin (d17:1, C22:0) 0.7423 down 9.8E−12 SM_Sphingomyelin (d17:1, C23:0) 0.6392 down 1.4E−11 CE_Cholesterylester C15:0 0.6745 down 8.8E−11 Cholesterylester C18:2 0.7013 down 2.1E−10 SM_Sphingomyelin (d16:1, C23:0) 0.7103 down 2.7E−10 Isocitrate 1.2983 up 4.6E−10 1-Hydroxy-2-amino-(cis,trans)-3,5- 0.738 down 1.2E−09 octadecadiene (from sphingolipids) Noradrenaline (Norepinephrine) 1.5067 up 4.9E−09 SM_Sphingomyelin (d16:1, C22:0) 0.7499 down 8.7E−09 SM_Sphingomyelin (d16:1, C24:0) 0.6773 down 1.1E−08 Maltose 1.8136 up 1.9E−08 SM_Sphingomyelin (d18:2, C23:0) 0.8134 down 2.7E−08 SM_Sphingomyelin (d17:1, C20:0) 0.7884 down   3E−08 SM_Sphingomyelin (d17:1, C16:0) 0.8169 down 1.6E−07 SM_Sphingomyelin (d18:1, C14:0) 0.8274 down 2.5E−07 CE_Cholesterylester C14:0 0.7641 down 5.2E−07 Sphingomyelin (d18:1, C23:0) 0.8793 down 6.2E−07 CER_Ceramide (d17:1, C24:0) 0.7452 down 1.7E−06 SM_Sphingomyelin (d18:2, C24:0) 0.834 down 2.3E−06 Uridine 0.7617 down 3.4E−06 CER_Ceramide (d18:2, C14:0) 0.7732 down 6.9E−06 CER_Ceramide (d17:1, C23:0) 0.7443 down   9E−06 SM_Sphingomyelin (d16:1, C20:0) 0.8091 down   1E−05 SM_Sphingomyelin (d17:1, C24:1) 0.8482 down 2.2E−05 SM_Sphingomyelin (d17:1, C18:0) 0.8393 down   3E−05 CE_Cholesterylester C22:6 0.7561 down 3.3E−05 SM_Sphingomyelin (d16:1, C22:1) 0.8034 down 3.6E−05 myo-Inositol 1.16 up 4.6E−05 CER_Ceramide (d16:1, C24:0) 0.762 down 6.7E−05 beta-Carotene 0.7066 down 8.1E−05 SM_Sphingomyelin (d16:1, C24:1) 0.8446 down 0.00011 Ornithine 1.1516 up 0.00012 SM_Sphingomyelin (d18:2, C22:0) 0.8501 down 0.00013 Cholesta-2,4,6-triene 0.8494 down 0.00016 TAG (C16:0, C18:2) 1.3317 up 0.00017 CE_Cholesterylester C16:2 0.7746 down 0.00017 CE_Cholesterylester C20:5 0.7085 down 0.00018 Sorbitol 1.5523 up 0.00019 SM_Sphingomyelin (d18:2, C23:1) 0.8561 down 0.00021 Isopalmitic acid (C16:0) 0.7684 down 0.00022 Sarcosine 1.1039 up 0.00024 Phosphatidylcholine (C18:2, C20:4) 0.9367 down 0.00025 CER_Ceramide (d18:1, C14:0) 0.8316 down 0.00026 SM_Sphingomyelin (d16:1, C18:1) 0.8335 down 0.00031 Sphingosine-1-phosphate (d17:1) 0.8268 down 0.00032 TAG (C16:0, C18:1, C18:2) 1.4134 up 0.00034 SM_Sphingomyelin (d16:1, C21:0) 0.8077 down 0.00038 CER_Ceramide (d16:1, C23:0) 0.7763 down 0.00038 Docosahexaenoic acid 0.7778 down 0.00044 (C22:cis[4,7,10,13,16,19]6) TAG (C18:1, C18:2) 1.3426 up 0.00053 Tyrosine 1.1292 up 0.00057 Testosterone 0.7956 down 0.00059 threo-Sphingosine (*1) 0.8766 down 0.00078 Phenylalanine 1.0929 up 0.00081 CE_Cholesterylester C14:1 0.68 down 0.00082 Cholesta-2,4-dien 0.8533 down 0.00096 SM_Sphingomyelin (d16:1, C16:0) 0.8766 down 0.00114 Malate 1.1907 up 0.00116 SM_Sphingomyelin (d18:1, C22:0) 0.8379 down 0.00119 CE_Cholesterylester C16:3 0.7918 down 0.00122 5-Oxoproline 1.0814 up 0.00123 CE_Cholesterylester C22:5 0.8603 down 0.00125 SM_Sphingomyelin (d18:1, C23:1) 0.8878 down 0.00132 Docosapentaenoic acid 0.8085 down 0.00165 (C22:cis[7,10,13,16,19]5) CER_Ceramide (d17:1, C16:0) 0.8577 down 0.00176 Taurine 1.1928 up 0.00178 Phosphatidylcholine (C16:0, C20:5) 0.9159 down 0.00195 SM_Sphingomyelin (d18:2, C14:0) 0.871 down 0.00207 Cholesterylester C18:1 0.8256 down 0.00219 CER_Ceramide (d17:1, C22:0) 0.8324 down 0.00247 CE_Cholesterylester C18:3 0.7933 down 0.00311 CER_Ceramide (d18:1, C18:0) 1.1562 up 0.00456 SM_Sphingomyelin (d18:2, C21:0) 0.8893 down 0.00466 CE_Cholesterylester C18:4 0.7197 down 0.00569 SM_Sphingomyelin (d16:1, C18:0) 0.8762 down 0.0057 Glycerol-3-phosphate, polar fraction 1.159 up 0.00613 Cholesterylester C16:0 0.8225 down 0.00685 Eicosapentaenoic acid 0.7853 down 0.00809 (C20:cis[5,8,11,14,17]5) CE_Cholesterylester C12:0 0.7224 down 0.00887 trans-4-Hydroxyproline 1.2178 up 0.0089 SM_Sphingomyelin (d18:1, C21:0) 0.9157 down 0.00945 CER_Ceramide (d18:2, C23:0) 0.869 down 0.00948 TAG (C16:0, C16:1) 1.2811 up 0.01131 Glycerol, lipid fraction 1.2809 up 0.01216 CER_Ceramide (d16:1, C16:0) 0.8776 down 0.0122 Cysteine 1.0714 up 0.01409 Phosphatidylcholine (C16:0, C20:4) 0.991 down 0.01571 8-Hydroxyeicosatetraenoic acid 1.2207 up 0.01617 (C20:trans[5]cis[9,11,14]4) (8-HETE) Hippuric acid 0.7043 down 0.01627 Sphingosine (d18:1) 1.264 up 0.01632 SM_Sphingomyelin (d18:2, C18:1) 0.9068 down 0.01633 Hexadecanol 1.1092 up 0.01765 14-Methylhexadecanoic acid 0.8393 down 0.01844 CER_Ceramide (d16:1, C22:0) 0.8608 down 0.02052 CER_Ceramide (d18:2, C24:0) 0.8903 down 0.02079 SM_Sphingomyelin (d18:2, C24:2) 0.9157 down 0.02116 Creatine 1.1628 up 0.02211 Eicosenoic acid (C20:cis[11]1) 1.1674 up 0.02337 14,15-Dihydroxyeicosatrienoic acid 1.1603 up 0.0238 (C20:cis[5,8,11]3) Sphinganine (d18:0) 1.2016 up 0.02412 CER_Ceramide (d18:1, C23:0) 0.8973 down 0.02646 CER_Ceramide (d17:1, C20:0) 0.876 down 0.02705 CER_Ceramide (d18:1, C24:0) 0.8982 down 0.02746 Fumarate 1.051 up 0.03023 SM_Sphingomyelin (d18:2, C20:0) 0.9289 down 0.03273 conjugated Linoleic acid 0.8624 down 0.03361 (C18:trans[9,11]2) 13-Hydroxyoctadecadienoic acid 1.1549 up 0.03371 (13-HODE) (C18:cis[9]trans[11]2) Campesterol 0.8211 down 0.03589 3,4-Dihydroxyphenylalanine (DOPA) 1.0983 up 0.03675 TAG (C18:2, C18:2) 1.2038 up 0.03696 Phosphatidylcholine No 02 0.9467 down 0.03922 Glucose-1-phosphate 1.089 up 0.03978 CER_Ceramide (d17:1, C24:1) 0.8986 down 0.04172 Lactaldehyde 1.0876 up 0.04225 Methionine 1.0698 up 0.04311 Lysophosphatidylethanolamine (C22:5) 0.9229 down 0.04472 scyllo-Inositol 1.1685 up 0.04903 CER_Ceramide (d16:1, C21:0) 0.8656 down 0.04997 (*1): free and from sphingolipids

TABLE 1b Metabolites of table 1a which additionally showed a significant difference (p-value < 0.1) between ischemic cardiomyopathy (ICMP) patients and healthy controls ratio of regula- Metabolite_Name median tion p-value Cholesterylester C18:2 0.6066 down 3.17E−17 SM_Sphingomyelin (d18:1, C14:0) 0.7751 down 3.88E−11 SM_Sphingomyelin (d18:2, C23:0) 0.7837 down 3.14E−10 SM_Sphingomyelin (d17:1, C23:0) 0.661 down 1.21E−09 Tricosanoic acid (C23:0) 0.7527 down 2.78E−09 CE_Cholesterylester C15:0 0.6948 down 5.44E−09 SM_Sphingomyelin (d17:1, C24:0) 0.7656 down 1.24E−08 1-Hydroxy-2-amino-(cis,trans)-3,5- 0.7463 down 1.33E−08 octadecadiene (from sphingolipids) Sorbitol 1.9715 up 3.76E−08 SM_Sphingomyelin (d17:1, C16:0) 0.8059 down 6.53E−08 SM_Sphingomyelin (d16:1, C23:0) 0.7416 down 7.29E−08 beta-Carotene 0.6178 down 1.71E−07 Glutamate 1.4858 up  2.7E−07 CE_Cholesterylester C14:0 0.7622 down 2.73E−07 SM_Sphingomyelin (d18:2, C23:1) 0.8017 down 4.36E−07 Cholesterylester C18:1 0.7308 down 4.92E−07 SM_Sphingomyelin (d18:2, C24:0) 0.82 down 6.35E−07 SM_Sphingomyelin (d17:1, C22:0) 0.8018 down  6.9E−07 SM_Sphingomyelin (d18:2, C24:2) 0.82 down 7.56E−07 Lignoceric acid (C24:0) 0.7793 down 8.82E−07 TAG (C16:0, C18:2) 1.4494 up  9.3E−07 threo-Sphingosine (*1) 0.8271 down 1.11E−06 SM_Sphingomyelin (d16:1, C24:0) 0.7192 down  2.4E−06 Sphingomyelin (d18:1, C23:0) 0.8821 down 2.52E−06 Phosphatidylcholine (C16:0, C20:4) 0.9828 down 2.97E−06 Lysophosphatidylcholine (C17:0) 0.8091 down 3.34E−06 Cholesterol, total 0.8639 down 3.68E−06 SP_Sphingosine-1-phosphate (d17:1) 0.7871 down 4.86E−06 TAG (C16:0, C18:1, C18:2) 1.5361 up 7.11E−06 Glucose 1.1273 up 8.77E−06 SM_Sphingomyelin (d17:1, C24:1) 0.8464 down 1.25E−05 TAG (C18:1, C18:2) 1.439 up 1.53E−05 Isocitrate 1.2014 up  1.7E−05 Phosphatidylcholine (C18:0, C18:2) 1.0183 up 2.19E−05 Zeaxanthin 0.7372 down 2.46E−05 CER_Ceramide (d18:1, C18:0) 1.2527 up 2.54E−05 Cysteine 1.1313 up 2.62E−05 SM_Sphingomyelin (d18:1, C23:1) 0.8504 down 2.65E−05 Behenic acid (C22:0) 0.839 down  2.7E−05 Maltose 1.5712 up 2.99E−05 Uric acid 1.1916 up 2.99E−05 erythro-C16-Sphingosine 0.7823 down 3.62E−05 SM_Sphingomyelin (d18:2, C14:0) 0.8257 down 4.08E−05 Cholesta-2,4-dien 0.8257 down 5.49E−05 Glucose-1-phosphate 1.1806 up 5.61E−05 5-O-Methylsphingosine (*1) 0.827 down 6.28E−05 Glycerol, lipid fraction 1.4758 up   7E−05 Pseudouridine 1.1483 up 7.79E−05 TAG (C16:0, C16:1) 1.4548 up 0.000109 SM_Sphingomyelin (d18:2, C22:0) 0.8469 down 0.00015 Cholesta-2,4,6-triene 0.8518 down 0.000167 SM_Sphingomyelin (d16:1, C22:0) 0.8256 down 0.00017 SM_Sphingomyelin (d16:1, C24:1) 0.845 down 0.000187 erythro-Sphingosine (*1) 0.8619 down 0.000211 Cystine 1.2256 up 0.00026 Linoleic acid (C18:cis[9,12]2) 0.8234 down 0.000276 3-O-Methylsphingosine (*1) 0.839 down 0.000315 Taurine 1.2195 up 0.000362 CER_Ceramide (d18:1, C14:0) 0.8309 down 0.000397 Dehydroepiandrosterone sulfate 0.6197 down 0.000427 Lysophosphatidylcholine (C18:2) 0.8578 down 0.000485 14,15-Dihydroxyeicosatrienoic acid 1.2659 up 0.000573 (C20:cis[5,8,11]3) CER_Ceramide (d17:1, C23:0) 0.7911 down 0.000631 TAG (C18:2, C18:2) 1.3485 up 0.000677 SM_Sphingomyelin (d16:1, C16:0) 0.8677 down 0.000709 Erythrol 1.1759 up 0.000711 CE_Cholesterylester C12:0 0.6467 down 0.000734 SM_Sphingomyelin (d16:1, C22:1) 0.8327 down 0.000787 Phytosphingosine, total 0.8621 down 0.000895 alpha-Ketoglutarate 1.1818 up 0.000916 8-Hydroxyeicosatetraenoic acid 1.3254 up 0.001168 (C20:trans[5]cis[9,11,4]4) (8-HETE) CER_Ceramide (d17:1, C24:0) 0.8152 down 0.001205 Cholesterylester C16:0 0.788 down 0.00143 CE_Cholesterylester C14:1 0.7029 down 0.001854 SM_Sphingomyelin (d18:1, C22:0) 0.8429 down 0.002434 SM_Sphingomyelin (d18:2, C21:0) 0.8781 down 0.002466 Eicosenoic acid (C20:cis[11]1) 1.2263 up 0.002476 Sarcosine 1.0878 up 0.002491 Adrenaline (Epinephrine) 1.4435 up 0.002549 Galactose, lipid fraction 0.8964 down 0.002702 SM_Sphingomyelin (d17:1, C20:0) 0.8783 down 0.002949 Isoleucine 1.1085 up 0.00385 Isopalmitic acid (C16:0) 0.8172 down 0.003877 CER_Ceramide (d18:2, C14:0) 0.8446 down 0.004044 CE_Cholesterylester C16:2 0.8272 down 0.004416 Normetanephrine 1.2896 up 0.004728 trans-4-Hydroxyproline 1.2407 up 0.005701 4-Hydroxy-3-methoxymandelic acid 1.6034 up 0.005745 Mannose 1.1511 up 0.006205 CE_Cholesterylester C22:5 0.8782 down 0.006918 5-Oxoproline 1.0658 up 0.007306 myo-Inositol 1.1023 up 0.009187 CE_Cholesterylester C22:6 0.8366 down 0.009822 SM_Sphingomyelin (d16:1, C21:0) 0.8596 down 0.010056 CER_Ceramide (d16:1, C23:0) 0.8277 down 0.010099 Lysophosphatidylcholine (C18:0) 0.9017 down 0.011903 Ornithine 1.0943 up 0.012027 Noradrenaline (Norepinephrine) 1.194 up 0.01265 SM_Sphingomyelin (d16:1, C18:1) 0.8798 down 0.013795 3-Methoxytyrosine 1.1696 up 0.016194 Cholestenol No 02 0.9013 down 0.016563 CE_Cholesterylester C18:3 0.8332 down 0.01764 CER_Ceramide (d16:1, C24:0) 0.8487 down 0.019382 Sphingomyelin (d18:1, C24:0) 0.9423 down 0.020541 Testosterone 0.8537 down 0.020931 5-Hydroxy-3-indoleacetic acid (5-HIAA) 1.1514 up 0.021745 CER_Ceramide (d18:2, C23:0) 0.8822 down 0.025435 SM_Sphingomyelin (d18:1, C21:0) 0.925 down 0.026263 Nervonic acid (C24:cis[15]1) 0.9114 down 0.026336 Phenylalanine 1.0625 up 0.0265 Phosphatidylcholine (C16:1, C18:2) 0.9229 down 0.030568 SM_Sphingomyelin (d18:2, C18:1) 0.9133 down 0.0313 CER_Ceramide (d17:1, C16:0) 0.8986 down 0.035021 Cryptoxanthin 0.8091 down 0.036128 Fumarate 1.0483 up 0.036755 Tyrosine 1.0777 up 0.038994 CE_Cholesterylester C20:5 0.8236 down 0.039914 CE_Cholesterylester C18:4 0.7902 down 0.043667 Malate 1.1101 up 0.046935 SM_Sphingomyelin (d16:1, C20:0) 0.9095 down 0.053287 CER_Ceramide (d17:1, C22:0) 0.8882 down 0.057993 Glycerol-3-phosphate, polar fraction 1.1093 up 0.061765 Uridine 0.8946 down 0.062565 SM_Sphingomyelin (d17:1, C18:0) 0.9258 down 0.072709 Hippuric acid 0.7791 down 0.081397 CER_Ceramide (d18:1, C23:0) 0.9177 down 0.089112 Phosphate, lipid fraction 0.9505 down 0.097734 (*1): free and from sphingolipids

TABLE 1c Metabolites of Table 1a which additionally showed a significant difference (p-value < 0.1) between hypertrophic cardiomyopathy (HCMP) patients and healthy controls ratio of regula- Metabolite_Name median tion p-value Maltose 2.1427 up 5.39E−11 Cholesterylester C18:2 0.7523 down 1.99E−06 Cholesterylester C18:1 0.7715 down 5.23E−05 Taurine 1.2525 up 9.72E−05 TAG (C16:0, C18:2) 1.2934 up 0.00091 Uric acid 1.1564 up 0.000939 TAG (C18:1, C18:2) 1.3302 up 0.00099 Glycerol, lipid fraction 1.3816 up 0.001367 TAG (C16:0, C18:1, C18:2) 1.3509 up 0.002192 CE_Cholesterylester C15:0 0.8215 down 0.002242 SP_Sphingosine-1-phosphate (d17:1) 0.8497 down 0.002442 SP_Sphinganine (d18:0) 1.2867 up 0.002474 SP_Sphingosine (d18:1) 1.3486 up 0.002704 Sarcosine 1.0901 up 0.003105 beta-Carotene 0.7568 down 0.003481 Cysteine 1.0924 up 0.003905 Tricosanoic acid (C23:0) 0.8682 down 0.004041 TAG (C16:0, C16:1) 1.3303 up 0.004263 Eicosenoic acid (C20:cis[11]1) 1.2145 up 0.005339 Isoleucine 1.1098 up 0.005399 Sphingomyelin (d18:1, C23:0) 0.926 down 0.005483 SM_Sphingomyelin (d18:2, C23:0) 0.897 down 0.006161 Noradrenaline (Norepinephrine) 1.2232 up 0.006926 Lysophosphatidylcholine (C17:0) 0.8834 down 0.008806 Testosterone 0.8292 down 0.009379 TAG (C18:2, C18:2) 1.2656 up 0.009482 Isocitrate 1.1189 up 0.011414 SM_Sphingomyelin (d17:1, C24:0) 0.885 down 0.011423 SM_Sphingomyelin (d17:1, C23:0) 0.8387 down 0.011783 Zeaxanthin 0.8283 down 0.012366 SM_Sphingomyelin (d16:1, C23:0) 0.869 down 0.014315 Cryptoxanthin 0.7778 down 0.018169 Erythrol 1.121 up 0.023299 CER_Ceramide (d17:1, C23:0) 0.8563 down 0.030171 Cholesterylester C16:0 0.8446 down 0.030834 SM_Sphingomyelin (d17:1, C22:0) 0.9062 down 0.032352 SM_Sphingomyelin (d18:1, C21:0) 0.9242 down 0.032429 SM_Sphingomyelin (d16:1, C21:0) 0.8795 down 0.034803 Glucose 1.0597 up 0.035437 Glutamate 1.1813 up 0.036213 Fumarate 1.0499 up 0.03758 SM_Sphingomyelin (d17:1, C20:0) 0.9101 down 0.039401 CE_Cholesterylester C14:0 0.8974 down 0.044159 Cystine 1.1237 up 0.044881 8-Hydroxyeicosatetraenoic acid 1.1957 up 0.047092 (C20:trans[5]cis[9,11,14]4) (8-HETE) 1-Hydroxy-2-amino-(cis,trans)-3,5- 0.9003 down 0.047207 octadecadiene (from sphingolipids) Uridine 0.8827 down 0.047309 Sorbitol 1.2852 up 0.048213 SM_Sphingomyelin (d18:1, C14:0) 0.9258 down 0.049457 Elaidic acid (C18:trans[9]1) 1.6069 up 0.05134 SM_Sphingomyelin (d18:2, C21:0) 0.9165 down 0.052457 Aspartate 1.0842 up 0.056222 Coenzyme Q10 1.1425 up 0.068217 CER_Ceramide (d18:1, C18:0) 1.1056 up 0.070545 SM_Sphingomyelin (d17:1, C16:0) 0.9289 down 0.07279 SM_Sphingomyelin (d18:2, C23:1) 0.9224 down 0.073683 Lactaldehyde 1.0822 up 0.078804 Pseudouridine 1.0653 up 0.082343 Hippuric acid 0.7733 down 0.083253 SM_Sphingomyelin (d18:1, C23:1) 0.9341 down 0.088944 CER_Ceramide (d17:1, C24:0) 0.8949 down 0.091594 Glucose-1-phosphate 1.0739 up 0.091687 SM_Sphingomyelin (d18:2, C24:0) 0.933 down 0.092261

TABLE 2 Metabolites with a significant difference (p-value < 0.05) in exercise-induced change between CHF and control ratio of regula- Metabolite median tion p-value Glutamate 0.724 down 0.000274 Hypoxanthine 0.448 down 0.000276 Adrenaline (Epinephrine) 0.439 down 0.001258 Lactate 0.612 down 0.005556 Indole-3-lactic acid 1.198 up 0.007027 Threonic acid 1.160 up 0.018026 Cholestenol No 02 0.906 down 0.022576 alpha-Tocotrienol 1.206 up 0.028952 Coenzyme Q9 1.166 up 0.029375 Histidine 1.083 up 0.039156 Phosphatidylcholine (C18:0, C20:4) 1.008 up 0.039198 Lysophosphatidylcholine (C18:1) 1.027 up 0.040233

TABLE 3 Metabolites with a significant difference (p-value < 0.05) between patients with CHF and healthy controls at the peak of exercise (t1) but not at rest (t0) Time point t0 t0 t0 t1 t1 t1 Metabolite ratio of median regulation p-value ratio of median regulation p-value Lactate 1.149 up 0.161549 0.705 down 0.015456 Citrate 1.118 up 0.256634 1.132 up 0.040482

TABLE 4a Metabolites with a significant difference (p-value < 0.05) between patients with CHF (dilated cardiomyopathy) with NYHA score 1 and healthy controls ratio of regula- Metabolite median tion p-value Mannose 2.168 up 0.000025 Lysophosphatidylcholine (C18:2) 0.699 down 0.000748 Adrenaline (Epinephrine) 2.411 up 0.004448 Hypoxanthine 1.779 up 0.004996 Phosphatidylcholine (C18:0, C18:2) 1.022 up 0.012486 Glucose 1.271 up 0.014916 Phosphate (inorganic and from organic 0.793 down 0.015030 phosphates) Cortisol 1.340 up 0.017261 Phosphatidylcholine (C18:0, C22:6) 1.239 up 0.017614 2-Hydroxybutyrate 1.810 up 0.019583 Corticosterone 1.293 up 0.019642 Androstenedione 1.785 up 0.035365 Glutamate 1.333 up 0.039299 Pentadecanol 0.581 down 0.044212 Maltose 1.7858 up 8.3846E−06 CE_Cholesterylester C15:0 0.7215 down  1.073E−05 Cholesterylester C18:2 0.7456 down 1.7406E−05 SM_Sphingomyelin (d17:1, C24:0) 0.7957 down 2.6209E−05 Noradrenaline (Norepinephrine) 1.4153 up 5.5355E−05 myo-Inositol 1.1987 up  6.44E−05 SM_Sphingomyelin (d17:1, C23:0) 0.731 down 8.1995E−05 SM_Sphingomyelin (d17:1, C22:0) 0.8196 down 0.00013927 Sorbitol 1.7458 up 0.00014037 Normetanephrine 1.5039 up 0.0001699 Isocitrate 1.2084 up 0.00019135 SM_Sphingomyelin (d18:1, C23:0) 0.8716 down 0.00026783 Ornithine 1.1704 up 0.00037428 Erythrol 1.2249 up 0.00040476 Sarcosine 1.1251 up 0.00042563 Cystine 1.2636 up 0.00044298 Testosterone 0.7586 down 0.00086625 CE_Cholesterylester C14:0 0.8093 down 0.0008742 Uridine 0.7862 down 0.00092815 SM_Sphingomyelin (d18:1, C14:0) 0.8622 down 0.00104019 Lignoceric acid (C24:0) 0.8223 down 0.00134372 Tricosanoic acid (C23:0) 0.8376 down 0.00139431 1-Hydroxy-2-amino-(cis,trans)-3,5- 0.8262 down 0.00145507 octadecadiene (from sphingolipids) SM_Sphingomyelin (d16:1, C24:0) 0.7694 down 0.00146283 Urea 1.2149 up 0.0015119 beta-Carotene 0.7083 down 0.00164813 Tyrosine 1.1473 up 0.001792 Behenic acid (C22:0) 0.8547 down 0.00192144 alpha-Ketoglutarate 1.218 up 0.00195906 SM_Sphingomyelin (d16:1, C23:0) 0.8262 down 0.00281307 Taurine 1.2111 up 0.00288466 SM_Sphingomyelin (d18:1, C24:0) 0.8827 down 0.0032925 3-Methoxytyrosine 1.259 up 0.00371589 Lysophosphatidylcholine (C17:0) 0.8552 down 0.00392246 SM_Sphingomyelin (d18:2, C23:0) 0.8797 down 0.00428746 CER_Ceramide (d18:2, C14:0) 0.8188 down 0.00445012 SM_Sphingomyelin (d17:1, C16:0) 0.8763 down 0.00489531 Cholesta-2,4,6-triene 0.8657 down 0.00545382 SM_Sphingomyelin (d18:2, C24:0) 0.8781 down 0.00576839 Phenylalanine 1.0947 up 0.00620035 Cysteine 1.1 up 0.00624402 SM_Sphingomyelin (d16:1, C22:0) 0.8502 down 0.00665211 Uric acid 1.1441 up 0.00696304 CER_Ceramide (d17:1, C24:0) 0.8237 down 0.00931215 Glucose-1-phosphate 1.1388 up 0.00940813 CE_Cholesterylester C22:5 0.8609 down 0.0095955 CE_Cholesterylester C16:2 0.8095 down 0.00966362 Dehydroepiandrosterone sulfate 0.6524 down 0.00995067 Glycerol-3-phosphate, polar fraction 1.1886 up 0.00997307 Isoleucine 1.1158 up 0.0102759 SM_Sphingomyelin (d17:1, C20:0) 0.8765 down 0.01056663 CER_Ceramide (d18:1, C14:0) 0.852 down 0.01059946 Cholesterol, total 0.9069 down 0.01060847 SM_Sphingomyelin (d18:1, C22:0) 0.8438 down 0.01179659 Linoleic acid (C18:cis[9,12]2) 0.8487 down 0.01208761 threo-Sphingosine (*1) 0.8906 down 0.01352672 SM_Sphingomyelin (d17:1, C24:1) 0.9005 down 0.01479843 CE_Cholesterylester C16:3 0.8114 down 0.01621643 CE_Cholesterylester C14:1 0.7197 down 0.01779781 Cholesterylester C18:1 0.837 down 0.01841802 scyllo-Inositol 1.2605 up 0.02009089 CE_Cholesterylester C22:6 0.8245 down 0.02009893 Pseudouridine 1.0972 up 0.02576962 CER_Ceramide (d17:1, C23:0) 0.8359 down 0.02705684 erythro-C16-Sphingosine 0.8592 down 0.02915249 Eicosenoic acid (C20:cis[11]1) 1.1968 up 0.02965701 SP_Sphinganine (d18:0) 1.2368 up 0.03058449 Isopalmitic acid (C16:0) 0.8326 down 0.03139525 Cholesta-2,4-dien 0.8837 down 0.03222468 Lysophosphatidylcholine (C18:0) 0.8999 down 0.03342501 Phosphatidylcholine (C16:1, C18:2) 0.9093 down 0.03389605 Cholesterylester C16:0 0.8258 down 0.03509819 TAG (C16:0, C18:2) 1.2113 up 0.03532712 SM_Sphingomyelin (d18:2, C22:0) 0.8964 down 0.03540009 CER_Ceramide (d17:1, C16:0) 0.8814 down 0.03839909 Glycerol, lipid fraction 1.2796 up 0.03879761 CE_Cholesterylester C18:3 0.8253 down 0.04166858 5-Oxoproline 1.0601 up 0.04385594 CE_Cholesterylester C22:4 0.8749 down 0.04444786 Serine, lipid fraction 1.2253 up 0.046845 5-O-Methylsphingosine (*1) 0.8943 down 0.04788647 TAG (C16:0, C18:1, C18:2) 1.2557 up 0.04838256 SP_Sphingosine (d18:1) 1.2602 up 0.04924965 (*1): free and from sphingolipids

TABLE 4b Metabolites of Table 4a which additionally showed a significant difference (p-value < 0.1) between ischemic cardiomyopathy (ICMP) patients with NYHA score 1 and healthy controls ratio of regula- Metabolite_Name median tion p-value Cholesterylester C18:2 0.6118 down 1.7191E−12 SM_Sphingomyelin (d18:1, C14:0) 0.7778 down 3.7018E−08 Sorbitol 2.0982 up 4.3743E−07 SM_Sphingomyelin (d18:2, C23:0) 0.8125 down 4.0589E−06 SM_Sphingomyelin (d17:1, C23:0) 0.7067 down 1.1938E−05 CE_Cholesterylester C15:0 0.7269 down  1.472E−05 SM_Sphingomyelin (d18:1, C23:0) 0.8512 down 1.8295E−05 TAG (C16:0, C18:2) 1.453 up 1.8737E−05 Cholesterylester C18:1 0.7343 down  1.939E−05 Tricosanoic acid (C23:0) 0.7919 down 2.5541E−05 1-Hydroxy-2-amino-(cis,trans)- 0.7813 down 3.8025E−05 3,5-octadecadiene (from sphingolipids) Cholesterol, total 0.8603 down 3.8932E−05 TAG (C16:0, C18:1, C18:2) 1.572 up 4.2286E−05 SM_Sphingomyelin (d17:1, C16:0) 0.8268 down 5.0421E−05 CE_Cholesterylester C14:0 0.785 down 6.3189E−05 beta-Carotene 0.6577 down 0.00012609 threo-Sphingosine (*1) 0.8433 down 0.00014084 Cholesta-2,4-dien 0.8112 down 0.00014837 Lysophosphatidylcholine (C17:0) 0.8168 down 0.00018589 Glucose 1.1224 up 0.00021581 Glutamate 1.3974 up 0.00024219 SM_Sphingomyelin (d17:1, C24:0) 0.8216 down 0.00026196 Lignoceric acid (C24:0) 0.8114 down 0.00031083 SM_Sphingomyelin (d16:1, C23:0) 0.7977 down 0.00038589 Phosphatidylcholine (C18:0, C18:2) 1.0177 up 0.00040589 SM_Sphingomyelin (d18:2, C24:0) 0.8492 down 0.00049962 5-O-Methylsphingosine (*1) 0.8249 down 0.0006501 SM_Sphingomyelin (d17:1, C22:0) 0.8428 down 0.00094804 Cystine 1.2438 up 0.00096287 Taurine 1.2299 up 0.00120903 Glucose-1-phosphate 1.1646 up 0.00135235 SM_Sphingomyelin (d17:1, C24:1) 0.8718 down 0.00137508 Glycerol, lipid fraction 1.4351 up 0.00147588 Behenic acid (C22:0) 0.8594 down 0.00159109 SM_Sphingomyelin (d16:1, C24:0) 0.7739 down 0.00173184 Isocitrate 1.1685 up 0.00194376 Cysteine 1.1133 up 0.0019666 3-Methoxytyrosine 1.2542 up 0.00284987 CER_Ceramide (d18:1, C14:0) 0.8291 down 0.00290481 erythro-C16-Sphingosine 0.8147 down 0.00311066 Linoleic acid (C18:cis[9,12]2) 0.8385 down 0.00451392 Maltose 1.4331 up 0.00496723 Adrenaline (Epinephrine) 1.5012 up 0.00542671 SM_Sphingomyelin (d18:2, C22:0) 0.8703 down 0.00727388 Lysophosphatidylcholine (C18:2) 0.8695 down 0.00744797 Normetanephrine 1.3345 up 0.00759363 SM_Sphingomyelin (d18:1, C24:0) 0.8937 down 0.0076034 Cholesterylester C16:0 0.7884 down 0.00805685 Eicosenoic acid (C20:cis[11]1) 1.2302 up 0.00826261 Cholesta-2,4,6-triene 0.8784 down 0.00837711 CE_Cholesterylester C22:5 0.8605 down 0.00891577 Dehydroepiandrosterone sulfate 0.6661 down 0.00966052 Pseudouridine 1.1119 up 0.01037548 CE_Cholesterylester C22:4 0.8457 down 0.01129319 CE_Cholesterylester C14:1 0.7165 down 0.01133041 Lysophosphatidylcholine (C18:0) 0.8831 down 0.01177707 Uric acid 1.1327 up 0.01187686 SM_Sphingomyelin (d18:1, C22:0) 0.8458 down 0.01247557 Testosterone 0.8204 down 0.01585512 CER_Ceramide (d17:1, C23:0) 0.8278 down 0.02004195 SM_Sphingomyelin (d16:1, C22:0) 0.875 down 0.0242648 Noradrenaline (Norepinephrine) 1.2117 up 0.02471946 CE_Cholesterylester C16:2 0.8476 down 0.03239574 5-Oxoproline 1.0599 up 0.03394216 alpha-Ketoglutarate 1.1326 up 0.03826297 CER_Ceramide (d17:1, C24:0) 0.8583 down 0.04035007 Isopalmitic acid (C16:0) 0.8489 down 0.04227044 CE_Cholesterylester C18:3 0.8356 down 0.04430951 CE_Cholesterylester C22:6 0.8484 down 0.04599329 SM_Sphingomyelin (d17:1, C20:0) 0.9092 down 0.06237979 Isoleucine 1.0817 up 0.06356105 Tyrosine 1.083 up 0.06681343 Ornithine 1.0775 up 0.07275574 Phosphatidylcholine (C16:1, C18:2) 0.9234 down 0.0730987 Mannose 1.1099 up 0.07913279 myo-Inositol 1.08 up 0.08438868 (*1): free and from sphingolipids

TABLE 4c Metabolites of Table 4a which additionally showed a significant difference (p-value < 0.1) between HCMP patients with NYHA 1 scores and healthy controls ratio of regula- Metabolite_Name median tion p-value Maltose 2.3774 up 9.1877E−11 Cholesterylester C18:2 0.7422 down 1.5121E−05 Taurine 1.3057 up 4.2799E−05 Cholesterylester C18:1 0.7566 down 0.00017957 Isoleucine 1.1583 up 0.00067494 TAG (C16:0, C18:2) 1.3413 up 0.00106071 Sarcosine 1.1148 up 0.00123586 SP_Sphinganine (d18:0) 1.3661 up 0.00126025 SP_Sphingosine (d18:1) 1.4493 up 0.00135359 TAG (C16:0, C18:1, C18:2) 1.4301 up 0.00163138 CE_Cholesterylester C15:0 0.814 down 0.00544571 SM_Sphingomyelin (d18:1, C23:0) 0.9016 down 0.00613976 Tricosanoic acid (C23:0) 0.8591 down 0.00645307 SM_Sphingomyelin (d18:2, C23:0) 0.8856 down 0.00715908 Glycerol, lipid fraction 1.3643 up 0.00800466 Eicosenoic acid (C20:cis[11]1) 1.2284 up 0.01113831 SM_Sphingomyelin (d17:1, C23:0) 0.8234 down 0.01457624 Uric acid 1.1278 up 0.01663987 beta-Carotene 0.7703 down 0.01772396 Serine, lipid fraction 1.2593 up 0.02396587 Testosterone 0.8387 down 0.03444244 CE_Cholesterylester C22:5 0.8857 down 0.03705511 Noradrenaline (Norepinephrine) 1.1939 up 0.03929456 CE_Cholesterylester C22:4 0.8728 down 0.04240014 1-Hydroxy-2-amino-(cis,trans)- 0.8851 down 0.04256896 3,5-octadecadiene (from sphingolipids) Uridine 0.8639 down 0.04452619 Glutamate 1.199 up 0.04801547 Lysophosphatidylcholine (C17:0) 0.8984 down 0.04926739 SM_Sphingomyelin (d16:1, C23:0) 0.8842 down 0.05494844 Cholesterylester C16:0 0.8449 down 0.06302395 SM_Sphingomyelin (d18:1, C14:0) 0.9196 down 0.06434119 SM_Sphingomyelin (d17:1, C22:0) 0.9084 down 0.0655624 SM_Sphingomyelin (d18:2, C24:0) 0.9168 down 0.06627783 Erythrol 1.112 up 0.06717477 Isocitrate 1.097 up 0.06783798 SM_Sphingomyelin (d17:1, C20:0) 0.9104 down 0.06992485 SM_Sphingomyelin (d17:1, C24:0) 0.9103 down 0.08265925 CER_Ceramide (d18:2, C14:0) 0.8865 down 0.08795584

TABLE 5 Metabolites with a significant difference (p-value < 0.05) in exercise-induced change between CHF with NYHA score 1 and control ratio of regula- Metabolite median tion p-value Glutamate 0.720 down 0.025093 Hypoxanthine 0.407 down 0.034843 Phosphatidylcholine (C18:0, 020:4) 1.011 up 0.048864

TABLE 6 Metabolites with a significant difference (p-value < 0.05) between patients with CHF with NYHA score I at the peak of exercise (t1) but not at rest (t0) Time point t0 t0 t0 t1 t1 t1 Parameter ratio of regula- p-value ratio of regula- p-value median tion median tion Phosphati- 1.035900639 up 0.339994 1.054274585 up 0.049492 dylcholine (C18:0, C20:4)

TABLE 7 Chemical/physical properties of selected analytes. These biomarkers are characterized herein by chemical and physical properties. Metabolite Fragmentation pattern (GC-MS) and description Glycerol phosphate, Glycerol phosphate, lipid fraction represents the sum parameter of lipid fraction metabolites containing a glycerol-2-phosphate or a glycerol-3-phosphate moiety and being present in the lipid fraction after extraction and separation of the extract into a polar and a lipid fraction. 3-O-Methylsphingosine 3-O-Methylsphingosine exhibits the following characteristic ionic fragments if detected with GC/MS, applying electron impact (EI) ionization mass spectrometry, after acidic methanolysis and derivatisation with 2% O- methylhydroxylamine-hydrochlorid in pyridine and subsequently with N- methyl-N-trimethylsilyltrifluoracetamid: MS (EI, 70 eV): m/z (%): 204 (100), 73 (18), 205 (16), 206 (7), 354 (4), 442 (1). 5-O-Methylsphingosine 5-O-Methylsphingosine exhibits the following characteristic ionic fragments if detected with GC/MS, applying electron impact (EI) ionization mass spectrometry, after acidic methanolysis and derivatisation with 2% O- methylhydroxylamine-hydrochlorid in pyridine and subsequently with N- methyl-N-trimethylsilyltrifluoracetamid: MS (EI, 70 eV): m/z (%): 250 (100), 73 (34), 251 (19), 354 (14), 355 (4), 442 (1). Phosphatidyl- Phosphatidylcholine No 02 represents the sum parameter of phosphatidyl- choline No 02 cholines. It exhibits the following characteristic ionic species when detected with LC/MS, applying electro-spray ionization (ESI) mass spectrometry: mass-to-charge ratio (m/z) of the positively charged ionic species is 808.4 (+/−0.5). TAG TAG (C16:0, C16:1) represents the sum parameter of triacylglycerides (C16:0, C16:1) containing the combination of a C16:0 fatty acid unit and a C16:1 fatty acid unit. It exhibits the following characteristic ionic species when detected with LC/MS, applying electro-spray ionization (ESI) mass spectrometry: mass-to- charge ratio (m/z) of the positively charged ionic species is 549.6 (+/−0.5). TAG TAG (C16:0, C18:2) represents the sum parameter of triacylglycerides (C16:0, C18:2) containing the combination of a C16:0 fatty acid unit and a C18:2 fatty acid unit. It exhibits the following characteristic ionic species when detected with LC/MS, applying electro-spray ionization (ESI) mass spectrometry: mass-to- charge ratio (m/z) of the positively charged ionic species is 575.6 (+/−0.5). TAG TAG (C18:1, C18:2) represents the sum parameter of triacylglycerides (C18:1, C18:2) containing the combination of a C18:1 fatty acid unit and a C18:2 fatty acid unit. It exhibits the following characteristic ionic species when detected with LC/MS, applying electro-spray ionization (ESI) mass spectrometry: mass-to- charge ratio (m/z) of the positively charged ionic species is 601.6 (+/−0.5). TAG TAG (C18:2, C18:2) represents the sum parameter of triacylglycerides (C18:2, C18:2) containing the combination of two C18:2 fatty acid units. It exhibits the following characteristic ionic species when detected with LC/MS, applying electro- spray ionization (ESI) mass spectrometry: mass-to-charge ratio (m/z) of the positively charged ionic species is 599.6 (+/−0.5). Cholestenol No Cholestenol No 02 represents a Cholestenol isomer. It exhibits the following 02 characteristic ionic fragments if detected with GC/MS, applying electron impact (EI) ionization mass spectrometry, after acidic methanolysis and derivatisation with 2% O-methylhydroxylamine-hydrochlorid in pyridine and subsequently with N-methyl-N-trimethylsilyltrifluoracetamid: MS (EI, 70 eV): m/z (%): 143 (100), 458 (91), 73 (68), 81 (62), 95 (36), 185 (23), 327 (23), 368 (20), 255 (15), 429 (15).

Diagnostic and risk marker for diabetes according to WO2012/085890:

TABLE 8 Diabetes biomarker glyoxylate Diagnostic question Direction p-value Ratio glyoxylate Diabetes vs. healthy Up 0.011 1.23 Non-healthy (risk & diabetes) vs. healthy Up 0.017 1.13 subjects Risk by OGTT vs. healthy Up 0.024 1.16 All risk subjects vs. healthy Up 0.052 1.11 Glucose-based comparison positive (diabetes Up 0.0026 1.19 and risk subjects) vs. neg negative (healthy controls, (quantile thresholds with gap in glucose concentration) Correlation with numeric HbA1c Up 0.056 1.051 HbA1c-based comparison pos vs. neg Up 0.036 1.15 (standard thresholds with gap) HbA1c-based comparison pos vs. neg Up 0.039 1.13 (quantile thresholds with gap) Diabetes vs. IFG Up 0.095 1.15 IFG + IGT vs. healthy Up 0.0043 1.23 Diabetes vs. IGT Up 0.095 1.20 Diabetes detectable by fasting glucose vs. Up 0.0082 1.32 healthy

Diagnostic markers for diabetes according to WO2007/110357:

TABLE 9 New Diabetes-specific metabolites determined on entire dataset. Metabolites (“CHEMICAL NAME”) are sorted according to t-Test p-value (“p.t”) starting with most significant findings. Also, fold change values (“Fold-change”: mean signal ratios of diabetes patients divided by mean signal ratio of control subjects) and regulation type in diabetes patients (“Kind of regulation”: distinguishing whether fold change is above 1 (“up”) or below 1 (“down”)) are provided. Chemical name regulation fold change p.t 1,5-Anhydrosorbitol down 0.83 1.68E−10 Eicosenoic acid (C20:1) up 1.23 3.68E−09 Erythrol up 1.17 1.87E−08 Ribonic acid up 1.12 0.000207352 Tricosanoic acid (C23:0) down 0.91 0.000690021 Pentadecanol up 1.14 0.002821548 Campesterol down 0.92 0.008032527 Maleic Acid down 0.93 0.012630545 Melissic Acid (C30:0) down 0.97 0.032299205

TABLE 10 New Diabetes-specific metabolites determined on age-matched males. Metabolites (“CHEMICAL NAME”) are sorted according to t-Test p-value (“p.t”) starting with most significant findings. Also, fold change values (“Fold-change”: mean signal ratios of diabetes patients divided by mean signal ratio of control subjects) and regulation type in diabetes patients (“Kind of regulation”: distinguishing whether fold change is above 1 (“up”) or below 1 (“down”)) are provided. Chemical name regulation fold change p.t 1,5-Anhydrosorbitol down 0.715966162 5.46E−07 Eicosenoic acid (C20:1) up 1.289836715 0.00169478 Pentadecanol up 1.215689075 0.029197314

TABLE 11 New Diabetes-specific metabolites determined on age-matched females. Metabolites (“CHEMICAL NAME”) are sorted according to t-Test p-value (“p.t”) starting with most significant findings. Also, fold change values (“Fold-change”: mean signal ratios of diabetes patients divided by mean signal ratio of control subjects) and regulation type in diabetes patients (“Kind of regulation”: distinguishing whether fold change is above 1 (“up”) or below 1 (“down”)) are provided. Chemical name regulation fold change p.t Eicosenoic acid (C20:1) up 1.179797938 0.001492544 Campesterol down 0.808075198 0.003629138 Tricosanoic acid (C23:0) down 0.894095758 0.013812625 Ribonic acid up 1.138360459 0.01522522 Erythrol up 1.129463926 0.033964934

TABLE 12 New Diabetes-specific metabolites combined from Table 1-3. Metabolites (“CHEMICAL NAME”) are sorted according to t-Test p-value (“p.t”) starting with most significant findings. Also, fold change values (“Fold- change”: mean signal ratios of diabetes patients divided by mean signal ratio of control subjects) and regulation type in diabetes patients (“Kind of regulation”: distinguishing whether fold change is above 1 (“up”) or below 1 (“down”)) are provided. Chemical name regulation fold change p.t 1,5-Anhydrosorbitol down 0.829793095 1.68E−10 Eicosenoic acid (C20:1) up 1.232521755 3.68E−09 Erythrol up 1.165086499 1.87E−08 Ribonic acid up 1.123283244 0.000207352 Tricosanoic acid (C23:0) down 0.914819475 0.000690021 Pentadecanol up 1.137229303 0.002821548 Campesterol down 0.808075198 0.003629138 Maleic Acid down 0.925831953 0.012630545 Melissic Acid (C30:0) down 0.967955786 0.032299205

TABLE 13 Diabetes-specific metabolites determined on entire dataset. Metabolites (“CHEMICAL NAME”) are sorted according to t-Test p-value (“p.t”) starting with most significant findings. Also, fold change values (“Fold- change”: mean signal ratios of diabetes patients divided by mean signal ratio of control subjects) and regulation type in diabetes patients (“Kind of regulation”: distinguishing whether fold change is above 1 (“up”) or below 1 (“down”)) are provided. The trivial finding of significantly altered Glucose levels of diabetes patients relative to control subjects was excluded from the table. fold Chemical name regulation change p.t Ascorbic acid up 1.46 3.36E−57 Mannose up 1.49 1.73E−42 Valine up 1.20 5.67E−21 Isoleucine up 1.23 4.91E−20 Leucine up 1.19 7.13E−18 Uric acid up 1.22 3.51E−17 Cysteine up 1.27 6.53E−15 putative DAG (C18:1,C18:2 or up 1.35 1.65E−14 C18:0,C18:3) Pyruvate up 1.43 1.08E−13 Glycerol, lipid fraction up 1.36 2.60E−13 Alanine up 1.16 9.73E−13 Docosahexaenoic acid up 1.35 2.92E−12 (C22:cis[4,7,10.13,16,19]6) a-Ketoisocaproic acid up 1.36 3.71E−12 Tyrosine up 1.15 3.94E−12 Coenzyme Q10 up 1.44 4.82E−12 Phenylalanine up 1.12 4.79E−10 Arachidonic acid up 1.18 1.03E−09 (C20:cis-[5,8,11,14]4) Palmitic acid (C16:0) up 1.16 2.25E−09 Glycine down 0.88 3.11E−07 Methionine up 1.12 3.97E−07 Eicosapentaenoic acid up 1.40 6.24E−07 (C20:cis[5,8,11.14,17]5) Proline up 1.13 8.62E−07 Pantothenic acid up 1.15 8.71E−07 Stearic acid (C18:0) up 1.12 1.88E−06 Citrate up 1.10 2.00E−06 Heptadecanoic acid (C17:0) up 1.13 3.08E−06 trans-9-Hexadecenoic acid up 1.23 1.01E−05 (C16:trans[9]1) Urea up 1.15 1.39E−05 Myristic acid (C14:0) up 1.24 2.07E−05 trans-4-Hydroxyprolin up 1.17 3.23E−05 3-Hydroxybutyric acid up 1.29 5.88E−05 Malate up 1.09 7.55E−05 Lignoceric acid (C24:0) down 0.92 0.000180162 myo-Inositol up 1.10 0.00026466 Phosphate (inorganic and from up 1.06 0.000360853 organic phosphates) Glycerol, polar fraction up 1.12 0.000497516 Lysine up 1.09 0.001206357 Creatinine up 1.12 0.004335171 Threonic acid down 0.90 0.00480835 Succinate down 0.93 0.005840745 Glyceric acid down 0.90 0.006088538 Linolenic acid (C18:cis[9,12,15]3) up 1.10 0.006887601 Lactate up 1.10 0.007055085 Glycerol-3-Phosphate, polar fraction up 1.08 0.010395131 Threonine down 0.95 0.011333993 Phosphate, lipid (Phospholipids) down 0.96 0.011654865 alpha-Tocopherol up 1.15 0.01644293 myo-Inositol-2-monophosphate, up 1.10 0.023497772 lipid fraction (myo-Inositolphospholipids) Linoleic acid (C18:cis[9,12]2) up 1.05 0.029803521 Cholesterol down 0.95 0.040018899 Tryptophane up 1.04 0.044645682 Glutamine up 1.08 0.048316597

TABLE 14 Diabetes-specific metabolites determined on age-mached males. Metabolites (“CHEMICAL NAME”) are sorted according to t-Test p-value (“p.t”) starting with most significant findings. Also, fold change values (“Fold-change”: mean signal ratios of diabetes patients divided by mean signal ratio of control subjects) and regulation type in diabetes patients (“Kind of regulation”: distinguishing whether fold change is above 1 (“up”) or below 1 (“down”)) are provided. The trivial finding of significantly altered Glucose levels of diabetes patients relative to control subjects was excluded from the table. Chemical name regulation fold change p.t Ascorbic acid up 1.484165764 4.48E−16 Mannose up 1.441573139 1.02E−10 Triacylglycerides (containing up 1.241759768 5.15E−06 C16:1, C18:1 or C16:0) Glycerol, lipid fraction up 1.450283984 0.000120249 Valine up 1.1519912 0.000250545 Glycine down 0.893625097 0.000402058 Uric acid up 1.154617325 0.000417209 Alanine up 1.135942086 0.000824962 Isoleucine up 1.14342636 0.000977933 Leucine up 1.122545097 0.001040907 a-Ketoisocaproic acid up 1.237299055 0.001333169 Cysteine up 1.185825621 0.002788438 trans-9-Hexadecenoic acid up 1.335554411 0.003179817 (C16:trans[9]1) Palmitic acid (C16:0) up 1.154644873 0.00355258 Phosphate (inorganic and from up 1.085474184 0.003897319 organic phosphates) Tyrosine up 1.101189829 0.006262303 Pantothenic acid up 1.150110477 0.008641156 Myristic acid (C14:0) up 1.347548843 0.00904407 Coenzyme Q10 up 1.358078148 0.010579477 Pyruvate up 1.219379362 0.01116163 Stearic acid (C18:0) up 1.135222404 0.01651251 Heptadecanoic acid (C17:0) up 1.135873084 0.016656669 Arachidonic acid up 1.113293751 0.017485633 (C20:cis-[5,8,11,14]4) Citrate up 1.085160753 0.017527845 Threonic acid down 0.841572782 0.02001934 Threonine down 0.92665537 0.029210563 Proline up 1.103973996 0.034468001 Phenylalanine up 1.088412821 0.035540147 Glycerol, polar fraction up 1.146918974 0.038229859 Ornithine down 0.920136988 0.042452599 Malate up 1.104999923 0.04703203

TABLE 15 Diabetes-specific metabolites determined on age-mached females. Metabolites (“CHEMICAL NAME”) are sorted according to t-Test p-value (“p.t”) starting with most significant findings. Also, fold change values (“Fold-change”: mean signal ratios of diabetes patients divided by mean signal ratio of control subjects) and regulation type in diabetes patients (“Kind of regulation”: distinguishing whether fold change is above 1 (“up”) or below 1 (“down”)) are provided. The trivial finding of significantly altered Glucose levels of diabetes patients relative to control subjects was excluded from the table. Chemical name regulation fold change p.t Ascorbic acid up 1.380715922 2.95E−15 Mannose up 1.462099754 2.85E−14 Isoleucine up 1.249533174 3.91E−10 Valine up 1.216130562 9.47E−10 Leucine up 1.209312876 4.11E−09 Uric acid up 1.212338486 3.68E−07 putative DAG (C18:1,C18:2 or up 1.334873111 1.96E−06 C18:0,C18:3) Pyruvate up 1.422173491 2.55E−06 Glycerol, lipid fraction up 1.293094601 3.32E−06 Cysteine up 1.218774727 2.91E−05 Alanine up 1.151999587 3.40E−05 Arachidonic acid up 1.184397856 4.34E−05 (C20:cis-[5,8,11,14]4) a-Ketoisocaproic acid up 1.331702228 6.58E−05 Tyrosine up 1.140901171 7.41E−05 Phenylalanine up 1.117874407 0.000102016 Palmitic acid (C16:0) up 1.151136844 0.000163626 Docosahexaenoic acid up 1.26073495 0.000260771 (C22:cis[4,7,10,13,16,19]6) Glycine down 0.865358103 0.000565068 Stearic acid (C18:0) up 1.111573897 0.00072957 Coenzyme Q10 up 1.266195595 0.000749378 Methionine up 1.105511152 0.002156394 Proline up 1.12556561 0.002831665 Citrulline down 0.913837925 0.004639509 Eicosapentaenoic acid up 1.365025845 0.005431358 (C20:cis[5,8,11,14,17]5) Phosphate (inorganic and from up 1.081308636 0.006424403 organic phosphates) Tryptophane up 1.072449337 0.011971631 3-Hydroxybutyric acid up 1.173601577 0.012617371 Heptadecanoic acid (C17:0) up 1.101194333 0.014202784 trans-9-Hexadecenoic acid up 1.171432156 0.014395605 (C16:trans[9]1) Lignoceric acid (C24:0) down 0.904681793 0.014423836 Malate up 1.094591121 0.019963926 Myristic acid (C14:0) up 1.161581037 0.022090354 Glycerol, polar fraction up 1.112976588 0.039329749 trans-4-Hydroxyprolin up 1.155965403 0.048937139

TABLE 16 Diabetes-specific metabolites combined from Table 1-3. Metabolites (“CHEMICAL NAME”) are sorted according to t-Test p-value (“p.t”) starting with most significant findings. Also, fold change values (“Fold-change”: mean signal ratios of diabetes patients divided by mean signal ratio of control subjects) and regulation type in diabetes patients (“Kind of regulation”: distinguishing whether fold change is above 1 (“up”) or below 1 (“down”)) are provided. The trivial finding of significantly altered Glucose levels of diabetes patients relative to control subjects was excluded from the table. Chemical name regulation fold change p.t Ascorbic acid up 1.460897562 3.36E−57 Mannose up 1.49099366 1.73E−42 Valine up 1.201219187 5.67E−21 Isoleucine up 1.226340595 4.91E−20 Leucine up 1.189558225 7.13E−18 Uric acid up 1.221580228 3.51E−17 Cysteine up 1.272344952 6.53E−15 putative DAG (C18:1,C18:2 or up 1.354261116 1.65E−14 C18:0,C18:3) Pyruvate up 1.428873302 1.08E−13 Glycerol, lipid fraction up 1.356574719 2.60E−13 Alanine up 1.1628012 9.73E−13 Docosahexaenoic acid up 1.351684129 2.92E−12 (C22:cis[4,7,10,13,16,19]6) a-Ketoisocaproic acid up 1.355419473 3.71E−12 Tyrosine up 1.147988422 3.94E−12 Coenzyme Q10 up 1.437313752 4.82E−12 Phenylalanine up 1.121836648 4.79E−10 Arachidonic acid up 1.177263087 1.03E−09 (C20:cis-[5,8,11,14]4) Palmitic acid (C16:0) up 1.157367192 2.25E−09 Glycine down 0.883191047 3.11E−07 Methionine up 1.122195372 3.97E−07 Eicosapentaenoic acid up 1.403223234 6.24E−07 (C20:cis[5,8,11,14,17]5) Proline up 1.13167844 8.62E−07 Pantothenic acid up 1.154905329 8.71E−07 Stearic acid (C18:0) up 1.11726154 1.88E−06 Citrate up 1.098766652 2.00E−06 Heptadecanoic acid (C17:0) up 1.13334341 3.08E−06 trans-9-Hexadecenoic acid up 1.231675019 1.01E−05 (C16:trans[9]1) Urea up 1.14574428 1.39E−05 Myristic acid (C14:0) up 1.243213274 2.07E−05 trans-4-Hydroxyprolin up 1.170068568 3.23E−05 3-Hydroxybutyric acid up 1.289932939 5.88E−05 Malate up 1.094925736 7.55E−05 Lignoceric acid (C24:0) down 0.917996389 0.000180162 myo-Inositol up 1.101603199 0.00026466 Phosphate (inorganic and from up 1.063347665 0.000360853 organic phosphates) Glycerol, polar fraction up 1.124778954 0.000497516 Lysine up 1.090319289 0.001206357 Creatinine up 1.121185726 0.004335171 Citrulline down 0.913837925 0.004639509 Threonic acid down 0.899837419 0.00480835 Succinate down 0.92986853 0.005840745 Glyceric acid down 0.903105894 0.006088538 Linolenic acid up 1.095025387 0.006887601 (C18:cis[9,12,15]3) Lactate up 1.104215189 0.007055085 Glycerol-3-Phosphate, up 1.084629455 0.010395131 polar fraction Threonine down 0.95499908 0.011333993 Phosphate, lipid (Phospholipids) down 0.958528553 0.011654865 Tryptophane up 1.072449337 0.011971631 alpha-Tocopherol up 1.14791735 0.01644293 myo-Inositol-2-monophosphate, up 1.097917328 0.023497772 lipid fraction (myo-Inositolphospholipids) Linoleic acid (C18:cis[9,12]2) up 1.048610793 0.029803521 Cholesterol down 0.946204153 0.040018899 Ornithine down 0.920136988 0.042452599 Glutamine up 1.075976861 0.048316597

Diabetes risk markers according to WO2007/110358:

TABLE 17 Overall results. Metabolites differing significantly (p < 0.05) between risk groups for Diabetes mellitus type 2 (IFG, IGT and IFG&IGT) and controls (significant main effect “risk”, i.e. same regulation type (“up”, “down”) in males and females.). Metabolites sorted by p-value. [IFG = Impaired Fasting Glucose; IGT = Impaired Glucose Tolerance; IFG&IGT: patients having both IFG and IGT] metabolite regulation risk_group cryptoxanthin down IGT 2-hydroxy-palmitic acid up IFG triacylglyceride (C16:0,C18:1,C18:2) up IGT gondoic acid up IGT tricosanoic acid down IFG&IGT 5-Oxoproline up IFG

TABLE 18 Metabolites differing specifically between male controls and male patients from risk groups for Diabetes. Metabolites differing significantly (p < 0.05) with regard to interaction risk-gender, i.e. differently regulated in males and females with regard to risk for Diabetes mellitus type 2 (IFG, IGT and IFG&IGT) and controls. Metabolites sorted by p-value. [IFG = Impaired Fasting Glucose; IGT = Impaired Glucose Tolerance; IFG&IGT: patients having both IFG and IGT] metabolite reg_male risk_group diacylglyceride (C18:1,C18:2) down IGT triacylglyceride (C16:0,C18:2,C18:2) down IGT triacylglyceride (C16:0,C18:1,C18:2) down IFG

TABLE 19 Overall results. Metabolites differing significantly (p < 0.05) between risk groups for Diabetes mellitus type 2 (IFG, IGT and IFG&IGT) and controls (significant main effect “risk”, i.e. same regulation type (“up”, “down”) in males and females.). Metabolites sorted by p-value. [IFG = Impaired Fasting Glucose; IGT = Impaired Glucose Tolerance; IFG&IGT: patients having both IFG and IGT] metabolite regulation risk_group lactate up IFG alpha-ketoisocaproic acid down IGT glucose up IFG&IGT methionine down IGT mannose up IFG&IGT 3-hydroxybutyric acid up IGT leucine up IGT uric acid up IFG threonic acid up IFG beta-carotene down IFG&IGT ascorbic acid up IFG&IGT glycine down IGT triacylglycerides down IFG lactate up IGT phospholipids up IGT creatinine down IGT glutamate up IFG alpha-ketoisocaproic acid down IFG&IGT triacylglycerides up IGT valine up IGT malate up IFG alpha-ketoisocaproic acid down IFG isoleucine up IGT succinate up IFG glucose-1-phosphate up IFG&IGT valine up IFG&IGT eicosapentaenoic acid (C20:cis[5,8,11,14, down IFG&IGT 17]5) phospholipids up IFG uric acid up IFG&IGT citrate up IGT aspargine down IFG&IGT methionine down IFG glutamine down IGT palmitic acid up IGT tryptophane down IFG&IGT alanine up IGT glutamate up IGT citrulline down IGT cholestenol down IFG&IGT threonine down IGT ornithine up IFG arginine down IGT mannose up IFG 3-hydroxybutyric acid up IFG&IGT glutamine down IFG pregnenolone sulfate up IFG&IGT glyceric acid up IGT folate up IFG malate up IGT beta-carotene down IFG leucine up IFG glutamine down IFG&IGT alpha-tocopherol up IFG&IGT myo-inositol up IFG stearic acid up IGT glycerol-3-phosphate up IFG beta-carotene down IGT

TABLE 20 Metabolites differing specifically between male controls and male patients from risk groups for Diabetes. Metabolites differing significantly (p < 0.05) with regard to interaction risk-gender, i.e. differently regulated in males and females with regard to risk for Diabetes mellitus type 2 (IFG, IGT and IFG&IGT) and controls. Metabolites sorted by p-value. [IFG = Impaired Fasting Glucose; IGT = Impaired Glucose Tolerance; IFG&IGT: patients having both IFG and IGT] metabolite reg_male risk_group tryptophane down IGT alanine down IFG leucine down IGT palmitic acid down IFG eicosatrienoic acid down IGT glycerophospholipids down IGT isoleucine down IFG eicosatrienoic acid down IFG tryptophane down IFG lignoceric acid down IGT linoleic acid down IGT serine up IFG tyrosine down IGT linoleic acid down IFG pregnenolone sulfate down IGT aspartate up IGT arachidonic acid down IGT succinate up IFG&IGT

TABLE 21 Metabolites differing specifically between female controls and female patients from risk groups for Diabetes. Metabolites differing significantly (p < 0.05) with regard to interaction risk-gender, i.e. differently regulated in males and females with regard to risk for Diabetes mellitus type 2 (IFG, IGT and IFG&IGT) and controls. Metabolites sorted by p-value. [IFG = Impaired Fasting Glucose; IGT = Impaired Glucose Tolerance; IFG&IGT: patients having both IFG and IGT] metabolite reg_female risk_group alanine up IFG palmitic acid up IFG isoleucine up IFG eicosatrienoic acid up IFG uric acid up IFG stearic acid up IFG serine down IFG

Example 2 Correlation of Plasma Metabolites with Cystatin C

In a metabolomics study comprising healthy individuals as well as patients with CHF of different types and severity classified according to NYHA stage and the correlation of metabolites with Cystatin C levels was investigated, using an ANOVA small polar metabolites were positively correlated in plasma (Table 22).

TABLE 22 Correlation of metabolites with Cystatin C. Shown are metabolites that were positively correlated in human plasma with Cystatin C levels (p-value <0.05). Further shown is the ratio of that metabolites between healthy individuals as well as patients with CHF of different types and severity classified according to NYHA stage. METABOLITE_NAME PVALUE RATIO Aldosterone 0.0000587 1.3849 Pentadecenoic acid (C15:cis[10]1) 0.00484362 1.286 TAG_conjugated Linoleic acid 0.00274666 1.2257 (C18:cis[9]trans[11]2) PC_conjugated Linoleic acid 0.01436876 1.1917 (C18:cis[9]trans[11]2) Glycocholic acid 0.02083947 1.1854 FFA_Palmitoleic acid 0.00085376 1.179 (C16:cis[9]1) Sucrose 0.00169411 1.1771 Timolol 0.00676457 1.1751 FFA_conjugated Linoleic acid 0.01218157 1.1738 (C18:cis[9]trans[11]2) 4-Hydroxy-3-methoxymandelic acid 0.01604282 1.1641 18-Hydroxycorticosterone 0.02350604 1.1573 1-Methylhistidine 8.96E−08 1.1555 CE_Cholesterylester C14:1 0.00162974 1.1458 CE_Cholesterylester C12:0 0.00915302 1.1377 PE_cis-Vaccenic acid 0.01122019 1.1365 TAG_Myristic acid (C14:0) 0.01858981 1.1286 TAG_Palmitoleic acid 0.01751954 1.1273 (C16:cis[9]1) Pseudouridine 1.01E−21 1.1253 Lauric acid (C12:0) 0.01944424 1.1253 Galactonic acid 0.02827966 1.1172 FFA_Myristic acid (C14:0) 0.00043414 1.1166 Glycerol-3-phosphate, polar fraction 0.00251244 1.1153 Lactose 0.0083945 1.1142 TAG (C16:0,C16:1) 0.00377556 1.1138 PI_dihomo-gamma-Linolenic acid (C20:cis[8, 0.01492842 1.1118 11,14]3) TAG_Eicosenoic acid (C20:cis[11]1) 0.01897445 1.1086 Homovanillic acid (HVA) 0.00049775 1.1079 Palmitoleic acid (C16:cis[9]1) 0.00308213 1.1066 Myristic acid (C14:0) 0.00703577 1.1064 Cystine 8.64E−07 1.105 Cellobiose 0.00904955 1.1028 PE_Linoleic acid (C18:cis[9,12]2) 0.00736073 1.1 CE_Cholesterylester C15:0 0.0000859 1.0994 Melezitose 0.02701434 1.0987 conjugated Linoleic acid (C18:trans[9,11]2) 0.00034109 1.0982 Sphingosine-1-phosphate (d16:1) 0.0000112 1.0966 Erythrol 5.52E−07 1.0956 PC_trans-Vaccenic acid 0.00806179 1.0955 (C18:trans[11]1) Metoprolol 0.0018019 1.0921 Phenacetin 0.0119848 1.0914 PE_Palmitic acid (C16:0) 0.01111048 1.091 Isopalmitic acid (C16:0) 0.00090355 1.0904 Norvaline 0.01594927 1.089 3-Methoxytyrosine 0.00046215 1.0878 myo-Inositol 2.15E−09 1.0875 CE_Cholesterylester C16:1 0.01203778 1.0866 PE_Stearic acid (C18:0) 0.02000861 1.0859 TAG_Stearic acid (C18:0) 0.03708277 1.0858 PC_Palmitoleic acid (C16:cis[9]1) 0.03528904 1.0845 TAG_Elaidic acid (C18:trans[9]1) 0.04166398 1.0833 PI_Oleic acid (C18:cis[9]1) 0.01087038 1.0822 Isocitrate 3.88E−07 1.0818 Creatinine 0.00162734 1.0812 Threitol 0.02038094 1.0811 PE_Oleic acid (C18:cis[9]1) 0.03203527 1.0804 TAG_Palmitic acid (C16:0) 0.03434188 1.0803 14-Methylhexadecanoic acid 0.00523372 1.0796 Urea 0.00572012 1.0795 CER_Ceramide (d16:1,C22:1) 0.01363344 1.0795 Kynurenic acid 0.00887948 1.0791 Proline 0.00010698 1.0783 PI_Palmitic acid (C16:0) 0.00447938 1.078 Sphingosine-1-phosphate (d17:1) 0.00013659 1.0767 Citrulline 0.0000601 1.0766 Glucose, lipid fraction 0.00880658 1.0758 Heptadecenoic acid (C17:cis[10]1) 0.00384771 1.075 PE_Palmitoleic acid (C16:cis[9]1) 0.01284879 1.0747 FFA_Oleic acid (C18:cis[9]1) 0.04512226 1.073 Norleucine 0.02655041 1.0729 PI_Linoleic acid (C18:cis[9,12]2) 0.03037486 1.0714 Ribonic acid 0.00065116 1.0711 alpha-Ketoglutarate 0.00031263 1.0697 Saccharic acid 0.01058718 1.0682 Glucose-1-phosphate 0.04620231 1.0674 CER_Ceramide (d18:2,C22:1) 0.01177441 1.0669 S-Adenosylhomocysteine 0.00085876 1.0668 CER_Ceramide (d18:1,C23:1) 0.00482234 1.0664 PI_cis-Vaccenic acid 0.03666484 1.0663 TAG (C16:0,C18:2) 0.02954298 1.0646 Uric acid 0.00011566 1.0645 Cystathionine 0.01743588 1.0643 PC_Docosapentaenoic acid 0.02400337 1.0643 (C22:cis[7,10,13,16,19]5) myo-Inositol-2-phosphate, lipid fraction 0.04247546 1.0637 trans-4-Hydroxyproline 0.0380941 1.0632 FFA_Palmitic acid (C16:0) 0.03262711 1.0611 Galactitol 0.00441193 1.0609 SM_Sphingomyelin (d18:2,C14:0) 0.00137019 1.0599 CER_Ceramide (d17:1,C16:0) 0.00481832 1.0572 CE_Cholesterylester C16:2 0.02663127 1.0569 CER_Ceramide (d18:1,C14:0) 0.00657081 1.0563 CER_Ceramide (d18:2,C14:0) 0.01441601 1.0559 MAG_Oleic acid (C18:cis[9]1) 0.03574089 1.0549 SM_Sphingomyelin (d18:1,C14:0) 0.00027973 1.0546 Sphingadienine-1-phosphate (d18:2) 0.00099076 1.0543 Cysteine 0.00000134 1.0541 7-Methylguanine 0.02521028 1.0537 CE_Cholesterylester C14:0 0.00691342 1.0536 Eicosenoic acid (C20:cis[11]1) 0.04645017 1.053 Malate 0.01003198 1.0505 PC_dihomo-gamma-Linolenic acid 0.03194076 1.0503 (C20:cis[8,11,14]3) CER_Ceramide (d18:1,C16:0) 0.00041067 1.049 Galactose, lipid fraction 0.0085052 1.0487 CER_Ceramide (d18:1,C22:1) 0.04844811 1.0471 MAG_cis-Vaccenic acid 0.03095777 1.0465 MAG_Palmitoleic acid (C16:cis[9]1) 0.03531624 1.0465 Cholesterol, free 0.00031928 1.046 Citrate 0.00520095 1.0459 CE_Cholesterylester C22:4 0.04253297 1.0456 CER_Ceramide (d16:1,C16:0) 0.03631033 1.0452 Erythronic acid 0.00345681 1.0449 SM_Sphingomyelin (d17:1,C16:0) 0.00421295 1.0449 Heptadecanoic acid (C17:0) 0.01706649 1.0444 CE_Cholesterylester C20:3 0.04978668 1.0434 CER_Ceramide (d18:2,024:2) 0.0485298 1.043 Ornithine 0.00233216 1.0411 Sphingosine-1-phosphate (d18:1) 0.02652481 1.0404 CER_Ceramide (d18:1,024:2) 0.0350854 1.0401 CER_Ceramide (d18:0,C16:0) 0.0417336 1.0395 CER_Ceramide (d18:2,C16:0) 0.01328616 1.0394 2-Hydroxypalmitic acid (C16:0) 0.01357086 1.0381 SM_Sphingomyelin (d16:1,C16:0) 0.02603957 1.0375 3,4-Dihydroxyphenylalanine (DOPA) 0.03324624 1.0365 Arginine 0.03208162 1.0319 SM_Sphingomyelin (d18:1,C23:1) 0.04107742 1.0309 PE_Elaidic acid (C18:trans[9]1) 0.00830393 1.0263 Phenylalanine 0.01504421 1.0262 SM_Sphingomyelin (d18:1,C16:0) 0.02973833 1.026 PE_trans-Vaccenic acid (C18:trans[11]1) 0.04596375 1.0242 SM_Sphingomyelin (d18:0,C16:0) 0.04518524 1.0238 Phosphatidylcholine (C18:0,C18:1) 0.02490652 1.0208 PC_Myristoleic acid (C14:cis[9]1) 0.00672447 1.0093 LPC_Docosatetraenoic acid (C22:cis[7,10, 0.02863556 1.0083 13,16]4)

Example 3 Correction of Plasma and Urine Metabolites for Renal Clearance

In a metabolomics study comprising healthy individuals as well as patients with CHF of different types and severity classified according to NYHA stage. The metabolic profile was analysed as described in anyone of WO2011/092285 A2, WO2012/085890, WO2007/110357 or WO2007/110358. The nomenclature of lipids from the analysis of complex lipids has been applied like described in WO2011/092285. Groups contained individuals with or without reduced renal function. A ANOVA was calculated based on a dataset using the ANOVA model (correcting for age, body mass index, gender, sample storage time, diabetes, see Table 23A, columns headed conf_int_diab) and second the ANOVA model including the additional normalization to cystatin C (see Table 23, columns headed conf_int_diab_CysC). The investigated patient group was classified according to diagnosis as DCMP or HCMP and the severity of the disease was classified according to NYHA.

Individuals with reduced renal function can be determined by significantly (p-value <0.05) increased Urea levels. A detail of the dataset with and without normalization to cystatin C is given in Table 23. The data were evaluated with and without normalization to cystatin C. We found the classic biomarker for CHF NT-BNP gives higher fold change values. For example: In the contrast subgroup NYHA group DCMP_II-III to control the fold change increased after cystatin C correction from 8.5928 to 9.0259, Table 23A while significance values remained highly significant with p-value of approximately 10E-22, Table23B). Simultaneously, the fold change of the renal kidney disease biomarker urea measured both by metabolite profiling and by conventional techniques became less by the normalization procedure. For example: In the contrast subgroup NYHA group DCMP_II-III to control the fold change of urea values determined in this study decreased after cystatin C correction from 1.103 to 1.0743 Table23A. At the same time the significance of these fold changes was less and p-values increased from 0.054782 to 0.170723, respectively, Table 23B.

These observations are in accordance with the invention described herein. This data demonstrated that normalization by cystatin C values compensates for the distortion of metabolite concentrations introduced by renal dysfunction. While CHF biomarkers show enhanced significance, renal dysfunction biomarkers show less significance.

TABLE 23 Detail from data table in CHF study demonstrating the effect of cystatin C normaliza- tion on the dataset. While the significance of the CHF biomarker NT-proBNP improves, signifi- cance of CKD biomarker Urea decreases. Other potential markers are included in the list. In the DCMP NYHAI group the patients generally have normal kidney function, consequently normali- zation via cystatin C does not effect the data much. A Without cystatin C normalization With cystatin C normalization Model_type conf_int_diab conf_int_diab conf_int_diab conf_int_diab conf_int_diab_ conf_int_diab_ conf_int_diab_ conf_int_diab_ CysC CysC CysC CysC Factor SUB- SUB- SUB- SUB- SUB- SUB- SUB- SUB- GROUP_ GROUP_ GROUP_ GROUP_ GROUP_ GROUP_ GROUP_ GROUP_ NYHA- NYHA- NYHA- NYHA- NYHA- NYHA- NYHA- NYHA- GROUP GROUP GROUP GROUP GROUP GROUP GROUP GROUP- Group DCMP_I- DCMP_II- HCMP_I- HCMP_II- DCMP_I- DCMP_II- HCMP_I- HCMP_II- I/II III I/II III I/II III I/II III References control control control control control control control control METAB- RATIO RATIO RATIO RATIO RATIO RATIO RATIO RATIO OLITE_ NAME NT-proBNP 4.5547 8.5928 1.6755 2.1366 5.0965 9.0259 1.7893 2.168 Isocitrate 1.2052 1.3852 1.0979 1.1462 1.228 1.3162 1.1205 1.1193 Urea 1.1463 1.1003 0.9792 1.1093 1.1386 1.0743 0.9847 1.0839 SM_Sphingo- 0.924 0.7919 0.9316 0.9581 0.9094 0.7932 0.9236 0.9349 myelfin (d17:1,C24:1) SM_Sphingo- 0.8909 0.7285 0.9004 0.9047 0.8525 0.7496 0.8856 0.8848 myelfin (d17:1,C20:0) SM_Sphingo- 0.8891 0.7666 0.8811 0.9123 0.8619 0.7884 0.8746 0.9005 myelfin (d18:2,C23:0) erythro-C16- 0.8608 0.647 0.9202 0.9629 0.8163 0.6174 0.9084 0.9148 Sphingosine SM_Sphingo- 0.8563 0.6732 0.9299 0.9449 0.7936 0.6629 0.914 0.9056 myelfin (d16:1,C22:0) Tricosanoic 0.844 0.6899 0.8573 0.8827 0.8248 0.7003 0.8546 0.8642 acid (C23:0) SM_Sphingo- 0.834 0.6229 0.8791 0.8449 0.7545 0.6059 0.8654 0.808 myelfin (d16:1,C23:0) 1-Hydroxy-2- 0.831 0.6707 0.8837 0.9224 0.8151 0.6522 0.878 0.8853 amino- (cis,trans)-3,5- octadecadiene (from sphin- golipids) SM_Sphingo- 0.818 0.6755 0.9113 0.9053 0.7652 0.6692 0.8983 0.8749 myelfin (d17:1,C22:0) SM_Sphingo- 0.795 0.6429 0.9127 0.8534 0.7504 0.6344 0.9046 0.8255 myelfin (d17:1,C24:0) SM_Sphingo- 0.7652 0.5994 0.8963 0.96 0.7354 0.5989 0.8835 0.9171 myelfin (d16:1,C24:0) Cholesteryl- 0.749 0.6681 0.7413 0.7695 0.7875 0.7499 0.7041 0.7726 ester C18:2 SM_Sphingo- 0.737 0.5707 0.8211 0.8594 0.6987 0.5801 0.8117 0.8216 myelfin (d17:1,C23:0) CE_Cholesteryl 0.709 0.6213 0.8249 0.835 0.6711 0.576 0.8448 0.7958 ester C15:0 B Without cystatin C normalization With cystatin C normalization Model_type conf_int_diab conf_int_diab conf_int_diab conf_int_diab conf_int_diab_ conf_int_diab_ conf_int_diab_ conf_int_diab_ CysC CysC CysC CysC Factor SUB- SUB- SUB- SUB- SUB- SUB- SUB- SUB- GROUP_ GROUP_ GROUP_ GROUP_ GROUP_ GROUP_ GROUP_ GROUP_ NYHA- NYHA- NYHA- NYHA- NYHA- NYHA- NYHA- NYHA- GROUP GROUP GROUP GROUP GROUP GROUP GROUP GROUP- Group DCMP_I- DCMP_II- HCMP_I- HCMP_II- DCMP_I- DCMP_II- HCMP_I- HCMP_II- I/II III I/II III I/II III I/II III References control control control control control control control control METAB- PVA- PVA- PVA- PVA- PVA- PVA- PVA- PVA- OLITE_ LUE LUE LUE LUE LUE LUE LUE LUE NAME NT-proBNP 4.82E−12 1.74E−22 0.0156078 0.0010168 2E−13  6.3E−22 0.0044124 0.00058346 Isocitrate 0.00024015 8.68E−11 0.0657395 0.012361 0.0000517  7.3E−08 0.0186496 0.0325252 Urea 0.00826734 0.0547822 0.6843029 0.0623397 0.0140049 0.17072336 0.7602796 0.14485695 SM_Sphingo- 0.08192016 3.09E−07 0.1099126 0.3553387 0.04905507 0.00000496 0.0760524 0.15704406 myelfin (d17:1,C24:1) SM_Sphingo- 0.03550351 1.04E−08 0.0501579 0.0741293 0.00517297 0.0000015 0.0215779 0.0294114 myelfin (d17:1,C20:0) SM_Sphingo- 0.01328734 2.54E−08 0.0063287 0.0580923 0.0033097 0.00000703 0.0043336 0.03530388 myelfin (d18:2,C23:0) erythro-C16- 0.03161874 3.26E−10 0.2348185 0.6144431 0.00611932 2.09E−10 0.1751897 0.24915906 Sphingosine SM_Sphingo- 0.01504927 8.45E−10 0.2411024 0.3826339 0.00059425 7.33E−09 0.1464397 0.13218534 myelfin (d16:1,C22:0) Tricosanoic 0.00205816 1.84E−11 0.0053604 0.0349024 0.0009378 1.84E−09 0.0049405 0.01644277 acid (C23:0) SM_Sphingo- 0.00774815 8.55E−12 0.0520314 0.0154343 0.0000805  4.1E−11 0.0277569 0.00236719 myelfin (d16:1,C23:0) 1-Hydroxy-2- 0.00197934 1.86E−11 0.0392421 0.2083086 0.00134181 5.98E−11 0.0330915 0.06709363 amino- (cis,trans)-3,5- octadecadiene (from sphin- golipids) SM_Sphingo- 0.00029769 3.18E−12 0.0838062 0.0772137 0.00000544 1.01E−10 0.0464069 0.01971957 myelfin (d17:1,C22:0) SM_Sphingo- 0.0000713 5.84E−14 0.1012501 0.0068472 0.00000457 7.46E−12 0.0797326 0.00174465 myelfin (d17:1,C24:0) SM_Sphingo- 0.00232813 6.77E−09 0.1990696 0.6473653 0.00113505 2.39E−07 0.1545728 0.34904969 myelfin (d16:1,C24:0) Cholesteryl- 0.0000236 1.74E−09 0.0000138 0.000364 0.00181547 0.00029474 0.0000011 0.00066417 ester C18:2 SM_Sphingo- 0.00030377 4.76E−11 0.0161611 0.0768364 0.0000654 8.13E−09 0.0116072 0.02521292 myelfin (d17:1,C23:0) CE_Cholesteryl 0.0000138 1.69E−09 0.0117082 0.0240509 0.00000179 3.29E−10 0.0269829 0.00498157 ester C15:0 

1-14. (canceled)
 15. A method for determining a clearance normalized amount of a metabolite disease biomarker in a sample comprising the steps of: (a) determining the amount of the metabolite disease biomarker in at least a first type of sample of a subject suspected to suffer from the disease; (b) determining the amount of a kidney function biomarker which correlates with the glomerular filtration rate (GFR) in the said at least first type of sample; and (c) determining a clearance normalized amount for the metabolite disease biomarker by normalizing the amount determined for the metabolite disease biomarker in step (a) to the amount of the kidney function biomarker determined in step (b), wherein said sample is blood or a derivative thereof.
 16. The method of claim 15, wherein said kidney function biomarker is selected from the group consisting of cystatin C.
 17. The method of claim 15, wherein said metabolite disease biomarker is a biomarker for cardiovascular diseases or disorders, diabetes or metabolic syndrome or neurodegenerative diseases.
 18. The method of claim 15, wherein said metabolite disease biomarker is a biomarker selected from any of tables 1 to 6 and 8 to
 21. 19. The method of claim 15, wherein said normalizing in step (c) encompasses calculating a ratio of the amount determined for the metabolite disease biomarker in step (a) and the amount of the kidney function biomarker determined in step (b).
 20. The method of claim 15, wherein steps (a) and (b) are additionally carried out for a second type of sample being different from the first type of sample and wherein said normalizing in step (c) encompasses calculating (i) a ratio of the amount determined for the metabolite disease biomarker in the first type and the second type samples, (ii) calculating a ratio of the kidney function biomarker determined in the first type and the second type samples, and (iii) calculating a ratio of the ratios calculated under (i) and (ii).
 21. A method for diagnosing a disease in a subject suspected to suffer therefrom comprising: (a) determining a clearance normalized amount for a metabolite disease biomarker in a sample of said subject according to the method of claim 15; and (b) comparing said clearance normalized amount to a reference, whereby the disease is to be diagnosed.
 22. The method of claim 21, wherein said disease is a cardiovascular diseases or disorders, diabetes or metabolic syndrome or neurodegenerative diseases.
 23. The method of claim 21, wherein said metabolite disease biomarker is a biomarker selected from any of tables 1 to 6 and 8 to
 21. 24. A device for determining a clearance normalized amount of a metabolite disease biomarker in a sample comprising: (a) an analyzing unit comprising a detection agent which specifically detects the amount of at least one metabolite disease biomarker and a detection agent which specifically detects the amount of a kidney function biomarker; and (b) an evaluation unit comprising a data processor having tangibly embedded a computer program code carrying out an algorithm which normalizes the amount for the metabolite disease biomarker to the amount of the kidney function biomarker.
 25. The device of claim 24, wherein said normalization encompasses calculating a ratio of the amount determined for the metabolite disease biomarker in step (a) and the amount of the kidney function biomarker determined in step (b)
 26. The device of claim 24, wherein said evaluation unit comprises a database with stored references which allow for diagnosing a disease based on the clearance normalized amount for the metabolite disease biomarker. 